### CERTIFICATE OF ELIGIBILITY **(COE)**

**Mi grant Bypass Contractor COE Require**  **ments R**  **EQUIRED DATA ELEMENTS Fam**  **ily Data Child Data**  Male Parent/Guardian Last Name Residency Date Male Parent/Guardian First Name Last name 1 Fem ale Parent/Guardian Last Name Last name 2 Fem ale Parent/Guardian First Name Suffix Current Address First name City Middle name State Sex Zip Birth Date Telephone Multiple Birth Flag (or MB) Birth Date Verification Code (or Code) **REQUIRED DATA SECTIONS Qualifying Move & Work**  **Section** 1. The child(ren) listed on this form mo ved from a residence in

__ ______ School district / City / State / Country

______ to a residence in

__ ______ School district / City / State

___ ___ ____ . 2. The child(ren) moved (complete both a. and b.) : a.  on ow

n as w orker, OR  wi th the worker, OR  to join or precede the w orker. b. T he w orker ,

______ First Name and Last Name of Worker

_______ , is the child or the child’s  parent  spouse  guardian. i. ( C om plete if “to join or precede” is checked in 2a. ) The worker moved on

__ __ MM/DD/YY

____ . The child(ren) mo ved on

_

___ MM/DD/YY

_

___ . ( provide c omment) 3. The Qualifying Arrival Date was

______ MM/DD/YY

_______ . 4. The w orker m oved due to economic necessity in order to obtain: a.  qualifying work, and obtained qualifying work, OR b.  any w ork, and obtained qualifying work soon after the move, OR c.  qualifying work specifically, but did not obtain the w ork. If the worker did not obtain the qualifying wo rk: i.  The w orker has a prior history of moves to obtain qualifying work ( provide c om me nt), OR ii.  There is other credible evidence that the worker actively sought qualifying work soon after the move ( provide co mme nt )
. 5. The qualifying w ork , *

___ ___ ___ describe agricultural or fishing work

_____ __ _ was (make a selection in both a. and b.): a.  seasonal OR  tem porary employment b.  agricultural OR  fishing wo rk 6. ( C om plete if “temporary” is checked in #5 a ) The w ork was determined to be temporary employment based on: a.  wo rker’s statement (provide comment), OR b.  employer’s statement (provide comment), OR c.  State documentation for

___ ___ ___ Em pl oyer

_ ___ ______ . **Comment Section (M**  **ust include 2bi, 4c, 5, 6**  **a and 6b of the Qualifying Move &**  **Work Section, if applicable )** 

**Parent/Guardian/Spouse/Worker Signature Section** I understand the purpose of this form is to help the Department’s contractor determine if the child(ren )/y outh listed on this form is/are eligible for the Title I, Part C Migrant Education Program. To the best of my knowledge, all of the information I provided to the interviewer is true. [This section must include fields labeled “Signature,” “Relationship t o the child(ren),” and “Date”.] *I f applicable, check:  personal subsistence (provide comment)

### CERTIFICATE OF ELIGIBILITY **(COE)**

**Mi grant Bypass Contractor COE Require**  **ments Eligibility**  **Certification Section** I certify that based on the information provided to me, which in all relevant aspects is reflected above, I am satisfied that these children are migratory children as defined in 20 U.S.C. 6399(2) and implementing regulations, and thus eligible as such for MEP services. I hereby certify that, to the best of my knowledge, the information is true, reliable, and valid and I understand that any false statement provided herein that I have made is subject to fine or im prisonment pursuant to 18 U.S.C. 1001. [The s ection must include fields labeled “Signature of Interviewer,” “Signature of Designated Reviewer,” and “Date” for each signature.]

### CERTIFICATE OF ELIGIBILITY **(COE)**

**Mi grant Bypass Contractor COE Require**  **ments** I. FAMILY DATA Male Parent/G

uardian: La stName FirstName Female Parent/Guardian: La st Name First Name Current Addre ss: City State Zip Telephone
II. CHI LD DATA

La st Name 1 La st Name 2 Suffix First Name Middle Name Sex Birth Date MB Code Residency Date

III. QUALIFYI

NG MOVE & WORK IV. COMMENTS (M ust include 2 bi, 4c, 5, 6a and 6b of the Qualifying Move & Work Section, if applicable. ) 1. The child(ren) listed on this form moved from a residence in School di strict / Cit y ____ /

__ State / Country to a residence in School di stri ct / Cit y / State . 2. The child(ren) moved (complete both a. and b.): a.  on ow

n as worker, OR  with t he worker, OR  to join or precede the worker. b. The worker, First Name and Last Name of Worker , is the child or the child’s  parent  spouse  guardian. i. (Complete if “to join or precede” is checked in 2a.) The wo rker moved on MM/DD/YY . The child(ren) moved on MM/DD/YY . (provide comment) 3. The Qualifying Arrival Date was MM/DD/YY . 4. The worker moved due to economic necessity in order to ob tain: a.  qualifying work, and obtained qualifying work, OR b.  any w ork, and obtained qualifying work soon after the move, OR c.  qualifying work specifically, but did not obtain the work. I f the worker did not obtain the qualifying work : i.  The worker has a prior history of moves to obtain qualifying work (provide comment), OR ii.  There is other credible evidence that the worker actively sought qualifying work soon after the move (provide c omment). 5. T he qualify

ing work,* describe agricultural or fishing work , was (make a selection in both a. and b.): a.  seasonal OR  temporary employment b.  agricultural OR  fishing work 6. (Complete if “temporary” is checked in #5 a ) The work was determined to be temporary employment based on: a.  worker’s statement (provide comment), OR b.  employer’s statement (provide comment), OR c.  State docum entation for Em plo yer . V. PARENT/GUARDIAN/SPOUSE/WORKER SIGNATURE I understand the purpose of this form is to help the Department ’ s contractor determine if the child ( ren )/ youth listed on this form is/are eligible for the Title I , Part C , Migrant Education Program. To the best of my knowledge, all of the information I provided to the interviewer is true.

____ ______________________________ ____ ______________________ __________________ Signatur e Relationship to the child (ren) Date VI. ELIGIBILITY DATA CERTIFICATION I certify that based on the information provided to me, which in all relevant aspects is reflected above, I am satisfied that these children are migratory children as defined in 20 U.S.C. 6399(2) and implementing regulations, and thus eligible as such for MEP services. I hereby certify that, to the best of my knowledge, the information is true, reliable, and valid and I understand that any false statement provided herein that I have made is subject to fine or imprisonment pursuant to 18 U.S.C. 1001.

_________________________________________ ____________________ Signature of I

nterviewer Date

______________________________ ___________ ____________________ Signature of D esignated Reviewer Date *If applicable, check:  personal subsistence (provide comment)

### CERTIFICATE OF ELIGIBILITY **(COE)**

**Mi grant Bypass Contractor COE Require**  **ments Privacy Act Statement**  The Department of Education (ED) has awarded a contract to the Central Susquehanna Intermediate Unit (CSIU), to assist the Department in administering the Mi grant Education Program in the States of Connecticut, Rhode Island, and West Virginia and to use the information provided to determ ine eligibility and to provide federal Migrant Education Program (MEP) services. Section 1307 of the Elementary and Secondary Education Act of 1965, as amended, gives ED the authority to ask these questions

. The Department collects your name, your chil d’s name, your spouse’s name, and your home address. ED also collects information about moves you and your spouse have made and the type of work you and your spouse do or have done in the past. The information includes the dates of birth for anyone whom ED determines is eligible for MEP services. ED will use this information to determine eligibility for MEP services, to provide educational services, and to retrieve records from our syst em. While individuals are not required to provide information on the COE form, ED requests this information because it is necessary for determining eligibility to receive MEP services. Without this information, ED cannot determine eligibility for MEP services and MEP services will not be provided even though individual s might meet the eligibility criteria. When ED decides that an individual is eligible for MEP services then we will disclose the information provided on the COE form to the Migrant Student Information Exchange (MSIX) system. MSIX, a system of records which we also maintain, will in turn non

- consensually disclose the information to State and local MEPs and local school districts, where you, your children, or your spouse enroll. Disclosing this information to the MSIX system results in the timely tran sfer of enrollment, placement, and credit accrual records. The Department also will publish a system of records notice (SORN) in the Federal Register because ED will retrieve records on migratory children and their families that our contractor CSIU col lects in the States of Connecticut, Rhode Island, and West Virginia

. This SORN will provide general notice to the public regarding the system’s locations, the categories of records that will be collected, the categories of individuals about whom informati on will be collected, the purposes of collecting the information, the authority for the collection, the routine use disclosures that the Department may make of the information in the system, and the safeguards that the Department and its contractor will em ploy to protect the records in the system. The system of records notice also will inform individuals of the procedures to request access to and amend their records in t he system of records. The routine uses summarized in the Privacy Act Statement provi de public notice of which categories of users and for what uses the Department may make non

- consensual disclosures of records from the particular system of records. It will indicate that the Department may disclose records from this system to the followin g:  authorized representatives of State educational agencies (SEAs), local educational agencies (LEAs), and other MEP local operating agencies that enroll the individual, or his or her children or spouse so that they may use the information to report on State assessments and to determine eligibility of migratory children for other Federal programs, such as the School Breakfast and National School Lunch Programs and the Summer Food Service Program;  to the Department’s contractor as part of the administrat ion and operation of the MEP;  to a researcher if an appropriate Department official determines that the researcher is qualified to carry out specific resea rch related to functions or purposes of the MEP and if the records are used solely for the purpose o f carrying out such research;  to the U.S. Department of Justice (DOJ) or the Office of Management and Budget (OMB) if it is desirable or necessary to obtai n DOJ’s or OMB’s advice on whether the Department must disclose records under the Freedom of Informa tion Act or the Privacy Act;  to agencies, entities, and persons whose assistance is needed by the Department in the course of responding to a breach of da ta in the system and to help the Department prevent, minimize, or remedy such harm;  to DOJ, an adjud icative body, parties, counsels, representatives or witnesses, if records are relevant and needed for litigation or alternative dispute resolution proceedings; and  to members of Congress or their staff who are seeking to resolve a written request, complai nt, or concern from the individual about whom the record in the system pertains. As indicated in the discussion above about the Privacy Act Statement, an individual is not required to provide this information to the Department, but the Department reques ts this information to determine eligibility to receive MEP services. Without this information, the Department cannot provide MEP ser vices to the individual. In addition, ED is not seeking individual consent for any particular uses of the information coll ected.