Reconsideration for Student Pandemic EBT (P-EBT) Benefits
Michigan Department of Health and Human Services
This form is for one student only. If you have more than one student, you will need to fill out another form like this one for each student. If you have questions when filling out this form, visit https://www.michigan.gov/PEBT
My student did not receive the expected amount in P-EBT benefits. I am asking for a review to reconsider my student’s P-EBT benefit or the amount they are eligible for.
SECTION 1
Before filling in your student’s information below, make sure the following statements are true. My student was signed up to receive free or reduced lunches at their school. My student is enrolled at a school building that qualifies for P-EBT. You can check this by: Visiting https://www.michigan.gov/PEBT. Clicking here (Pandemic-EBT) to see a list of schools that are eligible. Calling your student’s school.
Enter date your school became eligible
If these statements do not apply to your student, they are not eligible.
Student Name	Student’s Birthday (mm/dd/yyyy)
Student identification number - this is the number given to your student by the school building or district. If you are not able to find it, contact your student’s school. You must include this number
School district and building name – this is the name of the school district and the building where your student attends class or would be attending if they were going in person. Example: Lansing Public School District (School District) Lyons Elementary (School Building)
School District	School Building
SECTION 2
Fill in all the months you are requesting a reconsideration. Future months will not be considered. Your Student’s Enrollment – On the next page, put a X in the box that shows how your student attended school for every month you are asking for reconsideration. Check the in-person box if your student attended in-person (face to face) at their school all month, except for holidays, weekends, or sick days. •• Full days – student attended full days and had access to meal(s) at the school •• Half days – student attended half day and had no access to meal(s) Check online if your student did not go into the school building. They received the entire month of instruction on-line using a computer or tablet to connect with their teacher and classmates.

Check both online and in-person if your student did both online and in-person learning, at their school building, that month. Examples: •• Your student started the month either in person or online and changed during the month to another type of instruction. •• The school provided instruction a few days in person and did online instruction the other days. •• The school reduced in-person school hours and provided additional instruction on-line.
Month
In person (full day)	In person (half day)	Online	Both online and in person
Month
In person (full day)	In person (half day)	Online	Both online and in person
Month
In person (full day)	In person (half day)	Online	Both online and in person
Month
In person (full day)	In person (half day)	Online	Both online and in person
SECTION 3
Proof Document For every month you are asking for a reconsideration, you must get proof from your student’s school. This proof must be sent to you from any school employee, such as a teacher, secretary, counselor, or other school official. Someone that had knowledge of how your student attended school. If you do not provide this proof, your reconsideration will be denied. The proof document from the school must include all of the following: Student’s name The month for which you are requesting a reconsideration A statement from the school of how your student received instruction for that month Name of the school employee filling out the document The school employee’s title, e-mail, and telephone number
By checking the box below, attaching the proof document from the school, and signing this document, I am demonstrating that my student meets the requirements to get Pandemic EBT Benefits.
I have attached proof from my student’s school showing my child attended classes for each of the month(s) requested. If you request benefits without attaching your proof, it will be denied.
Read Carefully Before Signing I swear that all the information above is true. Making a false statement is considered fraud and/or perjury. I also understand that: If my child is active in any Food Assistance Program and/or Medicaid case, P-EBT benefits will be mailed to the address on file with the Michigan Department of Health and Human Services (MDHHS). All others will be mailed to the address provided by the school. If any person uses any plastic EBT card or food assistance benefits that he or she is not allowed to, they are violating federal and state laws and they can receive a heavy penalty.

This form must be completed, signed, and mailed to: MDHHS/SPO PO Box 30800, SUITE 1405 Lansing MI 48909 Or email the completed form to MDHHS-PEBT@michigan.gov.
The decision on this reconsideration is final. No hearing or appeal is allowed.
Printed Name	Phone Number
Signature	Date
If you have trouble filling out this form, visit https://www.michigan.gov/PEBT or call 833-905-0028.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender, identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
AUTHORITY: Federal 7 CFR. COMPLETION: Voluntary. PENALTY: Possible inability to issue P-EBT benefits.