CERTIFICATE OF ELIGIBILITY (COE)

Migrant Bypass Contractor COE Requirements

REQUIRED DATA ELEMENTS

Family Data Child Data

Male Parent/Guardian Last Name Residency Date

Male Parent/Guardian First Name Last name 1

Female Parent/Guardian Last Name Last name 2

Female 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 moved 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 own as worker, OR  with the 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 worker 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 obtain: 

 a.  qualifying work, and obtained qualifying work, OR 

b.  any work, and obtained qualifying work soon after the move, OR

c.  qualifying work specifically, but did not obtain the work. If 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 comment).

5. The qualifying 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 #5a) 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 documentation for _________Employer__________.

Comment Section (Must include 2bi, 4c, 5, 6a 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)/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. [This section must include fields labeled “Signature,” 

“Relationship to the child(ren),” and “Date”.]

*If applicable, check:

 personal subsistence (provide comment)
CERTIFICATE OF ELIGIBILITY (COE)

Migrant Bypass Contractor COE Requirements

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 

imprisonment pursuant to 18 U.S.C. 1001. [The section must include fields labeled “Signature of Interviewer,” 

“Signature of Designated Reviewer,” and “Date” for each signature.]

 
CERTIFICATE OF ELIGIBILITY (COE)

Migrant Bypass Contractor COE Requirements

I. FAMILY DATA

Male Parent/Guardian: LastName FirstName Female Parent/Guardian: Last Name First Name 

Current Address: City State Zip Telephone 

II. CHILD DATA

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

Date

III. QUALIFYING MOVE & WORK IV. COMMENTS (Must include 2bi, 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 district / City____ / 

__State / Country to a residence in School district / City / State .

2. The child(ren) moved (complete both a. and b.):

a.  on own as worker, OR  with the 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 worker 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 obtain: 

 a.  qualifying work, and obtained qualifying work, OR 

b.  any work, and obtained qualifying work soon after the move, OR

c.  qualifying work specifically, but did not obtain the work. If 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 comment).

5. The qualifying 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 #5a) 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 documentation for Employer .

 

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. 

__________________________________ __________________________ __________________

Signature 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 Interviewer Date

_________________________________________ ____________________

Signature of Designated Reviewer Date

*If applicable, check:

 personal subsistence (provide comment)
CERTIFICATE OF ELIGIBILITY (COE)

Migrant Bypass Contractor COE Requirements

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 Migrant Education 

Program in the States of Connecticut, Rhode Island, and West Virginia and to use the information provided to determine 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 child’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 system. 

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 individuals 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 transfer 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 collects 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 information 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 employ 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 the system of records. 

The routine uses summarized in the Privacy Act Statement provide 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 following:

 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 administration and operation of the MEP; 

 to a researcher if an appropriate Department official determines that the researcher is qualified to carry out specific research related to functions or purposes of the MEP and if 

the records are used solely for the purpose of 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 obtain DOJ’s or OMB’s advice on whether the 

Department must disclose records under the Freedom of Information 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 data in the system and to help the Department 

prevent, minimize, or remedy such harm; 

 to DOJ, an adjudicative 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, complaint, 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 requests this 

information to determine eligibility to receive MEP services. Without this information, the Department cannot provide MEP services to the individual. In addition, ED is not seeking 

individual consent for any particular uses of the information collected.