NEW JERSEY SUMMER EBT OPT OUT REQUEST FORM

Must be completed annually

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Dual participation in the Summer EBT program is prohibited. This means that children may not receive multiple benefit allotments from the same State, or from more than one State, each summer.

This is a form to DECLINE the receipt of Summer EBT benefits.

This is NOT an application for Summer EBT benefits. If you believe your child(ren) is eligible to receive benefits and they meet certain criteria, you may need to complete the School Meals and Summer EBT application at your child(ren)'s school. See the NJ Summer EBT webpage for more information.

The NJ Summer EBT Program provides low-income families with a one-time $120 EBT card per eligible child to help purchase groceries during the summer when kids might not have access to school meals. The New Jersey Department of Agriculture created this page for parents or guardians of eligible students to easily submit a request to opt their child(ren) out of receiving Summer EBT benefits. The information you provide will only be used to decline receipt of Summer EBT benefits.

This request should only be completed by the parent or guardian who has legal responsibility for the care of the student(s) during the summer months.

Be aware that submitting a request to opt your child(ren) out means that you do not want to receive Summer EBT benefits for the upcoming summer.

The information you share on each page will not be saved until the form is submitted. If you do not complete and submit the form in one sitting, you will need to start over and answer all the questions again.

Parent or Legal Guardian Information

Summer Year

First Name

Middle Initial

Last Name

Email Address

Phone Number

I don’t have a phone number.

Child’s Information

First Name

Middle Initial

Last Name

Date of Birth

Address

School Name

School District Name (SFA Name)

My child(ren) is home-schooled.

The information you provided will be used to opt out your child(ren) from receiving Summer EBT benefits for Summer 2026. To complete and submit your information, review the following sentences, check the “I certify” box below and then submit the opt out request.

I understand the questions and statements on this form.
I have the legal authority to make decisions regarding the child(ren) I listed.
I understand that my decision to have the child(ren) I listed opt out from Summer EBT benefits for Summer 2026 can only be changed by emailing the Summer EBT Support Team at DFNSummerEBT@ag.nj.gov
I am aware that if I purposely give false information or break the rules my child(ren) may lose Summer EBT beneﬁts and I may be prosecuted under applicable state and federal criminal laws.
I understand that I must opt out my eligible child(ren) from receiving Summer EBT each year.

I certify I am electronically signing this page. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. By signing this page electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge.

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FNS - SEBT Opt Out Request Form

NEW JERSEY SUMMER EBT OPT OUT REQUEST FORM

Parent or Legal Guardian Information

Child’s Information