School Nutrition Program- Community Eligibility Provision SY 20-21 
               Dear Parent or Guardian: 
               Polk School District School Nutrition Program is currently participating in Community 
               Eligibility Provision (C.E.P.) CEP provides funding of meals at no charge to all students. CEP 
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               is for a period of four years. SY 20/21 is the 4  year for this program.  We need your help 
               to justify continued funding of CEP. 
               We are asking that you fill out and sign the Household Information Survey. This 
               survey will be used to determine if Polk School District will be recertified as a CEP District.  
               This survey also establishes data that allows our school students to benefit from various 
               State and Federal Supplemental Programs such as Title I A, At Risk (31a), Title II A, E- 
               Rate, Community Eligibility for School Meals, etc.  We are asking that you please complete 
               and submit it as soon as possible.  You may mail the survey back to address at bottom of 
               this letter or return this form to your school’s lunchroom manager. 
               All information on the survey submitted is confidential. Without your assistance, the school 
               system cannot maximize utilization of available State and Federal funds.  
               If we can be of any further assistance, please contact us at 770-684-5447. 
               Sincerely, 
               Linda Holland, EdD, RD, SNS 
               School Nutrition Director 
                
               In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and 
               policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA 
               programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, 
               age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or 
               funded by USDA.  
               Persons with disabilities who require alternative means of communication for program information (e.g. Braille, 
               large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they 
               applied for benefits.  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA 
               through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in 
               languages other than English. 
               To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-
               3027) found online, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the 
               information requested in the form. To request a copy of the complaint form, call (866) 632-9992.  Submit your 
               completed form or letter to USDA by:  
               (1)     Mail: U.S. Department of Agriculture 
                       Office of the Assistant Secretary for Civil Rights 
                       1400 Independence Avenue, SW 
                       Washington, D.C. 20250-9410; 
               (2)     Fax: (202) 690-7442; or  
               (3)     Email: program.intake@usda.gov 
                                           This institution is an equal opportunity provider 
                
                     School Nutrition Program •2221 Old Cedartown Road, Cedartown, GA 30125 • 770-684-5447 
                                                                                                                                      
                                                     Community Eligibility Provision (CEP) 
                                              Household Information Survey 
               Dear Parent/Guardian: 
               To determine future eligibility and funding amounts for various additional State and Federal 
               Supplemental programs in Polk School District that benefit all Polk School District students please 
               complete, sign and return this survey to your child(ren)’s school lunchroom manager.  
                Does any living in your home receive SNAP, TANF, or FDPIR? If so provide name and 
                nine number (digit) case number for the person who receiving benefits AND list all 
                students living in your home in the spaces below: 
                 Name:__________________________________________________________ 
                                  (Please print name of person receiving benefits above) 
                9 digit Case #: ___   ___   ___   ___   ___   ___   ___   ___   ___  
                                                                
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                             Please list ALL students living in your home (Pre-K through 12  Grade) 
                                                                                                     Is this 
                                                                    Birth Date                      student 
                       Last Name               First Name                            School        Homeless 
                                                                  MM-DD-YYYY                           Or  
                                                                                                     Foster 
                  1.                                                                               
                  2.                                                                               
                  3.                                                                               
                  4.                                                                               
                  5.                                                                               
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                  8.                                                                               
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               I certify (promise) that all information on this survey is true and I understand that officials may verify (check) the information. 
                Parent/Guardian: _____________________________________/____________________________________________ 
                                                              Print                                                                     Signature 
               (Optional) Phone number you may be reached: _____________________________________________________ 
                
                     School Nutrition Program •2221 Old Cedartown Road, Cedartown, GA 30125 • 770-684-5447