SNAP, WIC, FMNP, and CN COVID-19 Waivers, Evaluation, and Reporting Data - State Agencies and WIC Local Government (SLT)

OMB 0584-0654; EXP. 11/30/2020

ATTACHMENT X: FMNP WAIVER REQUEST FORM

Food and Nutrition Service
Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
Farmers’ Market Nutrition Program COVID-19 Waiver Request Template

Introduction

Section 2204(a)(1) of the Families First Coronavirus Response Act (P.L. 116-127, the Act) provides Special
Supplemental Nutrition Program for Women, Infants and Children (WIC) Farmers’ Market Nutrition
Program (FMNP) State agencies, including participating Indian Tribal Organizations and U.S. Territories,
the opportunity to request a waiver of FMNP regulatory requirements from the U.S. Department of
Agriculture (USDA), Food and Nutrition Service (FNS). Such requests may only be granted if the State
agency: (1) cannot meet program regulatory requirements due to COVID-19, and (2) the waiver is
necessary to provide assistance to recipients. This waiver authority solely applies to requirements in FMNP
regulations at 7 CFR Part 248, not to requirements contained in Section 17(m) of the Child Nutrition Act of
1966 (CNA, P.L. 89-642). If a regulatory provision is also contained in the CNA, FNS cannot waive the
requirement.
USDA has the authority to provide waivers through September 30, 2020. State agency reporting
requirements apply. In particular, each State agency that receives waiver approval from USDA FNS must,
not later than 1 year after the date such State agency received the waiver, submit a report to the USDA FNS
Regional Office which includes: (1) a summary of the use of such waiver by the State agency; and (2) a
description of whether such waiver resulted in improved services to FMNP recipients.
Instructions
This template guides FMNP State agencies through the information FNS will need to evaluate your waiver
request. You are not required to use this template, but all of this information must be included in a written
request to FNS.
The comment boxes in the template application will expand as you type, so provide as much information as
necessary to support your request. If there is additional information that cannot be captured in the
template’s comment boxes, please include as an attachment. Section C and D are for pre-determined
waiver requests. If you need additional regulatory waiver requests, please use Section E and F. In order to
properly review your request and ensure all necessary information is captured, please submit only one
request per section.
All requests must be sent to the FNS Regional Office. The FNS Regional Office will in turn review your
request, ask questions if necessary, and forward the State agency’s request along with the Regional Office’s
recommendation for approval/disapproval to FNS National Office for review.
NOTE: Many program flexibilities exist which do not require a regulatory waiver. Please refer to
the document entitled FMNP Questions and Answers on Program Flexibilities during a Pandemic
before submitting a regulatory waiver request.
For full consideration, please complete all blue sections.

This information is being collected to assist the Food and Nutrition Service in managing information collection due to
COVID-19. This is a voluntary collection and FNS uses the information to approve waivers and collect data on their use.
This collection does not request any personally identifiable information under the Privacy Act of 1974. According to the
Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0584-0654. The time required to complete this information collection is estimated to average
0.25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place,
5th Floor, Alexandria, VA 22306 ATTN: PRAO. Do not return the completed form to this address.

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A. State Agency Information
State Agency: Enter State Agency Name.
Date Request Submitted: Click or tap to enter the date of submission.
State Agency Director Name: First Name

Last Name

Director Title: Title
State Agency Director Contact (555) 555-5555
Information:
State Agency Mailing Address: Full Address

Email

B. Overview
Please provide a brief summary of your request.
C. Waiver Request Details - Waiver Request for 7 CFR 248.10(a)(4) and (d)

(Requirement for face-to-face training)

“Yes” answers are required for Questions 1-3, along with all additional information requested below, for
FNS to consider your State agency’s waiver request.
1. Is your State agency requesting a
waiver of FMNP regulatory
requirement for face-to-face
training contained in 7 CFR Part
248.10(a)(4)?

Yes ☐
No ☐

If Yes, please provide a The State agency shall ensure that face-to-face training is
description of the regulatory conducted prior to start up of the first year of FMNP
requirement: participation of a farmers’ market and individual farmer.
2. Is your State agency making the
request because your State
FMNP cannot meet the
program’s regulatory
requirement due to COVID-19?

Yes ☐
No ☐

If Yes, please explain: Click or tap here to enter text.
3. Is the waiver necessary to
provide assistance to FMNP
recipients?

Yes ☐
No ☐

If Yes, please explain: Click or tap here to enter text.

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**For Regional Office Use ONLY **
Click or tap here to enter text.
FNS Regional Office Analysis:
(please include a description of any TA
provided to the SA and/or additional
important details about the SA that
would impact consideration of this
request)

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D. Waiver Request Details - Waiver Request for 7 CFR 248.10(b)(7)
(Requirement for Three-year Agreements)
“Yes” answers are required for Questions 1-3, along with all additional information requested below, for
FNS to consider your State agency’s waiver request.
1. Is your State agency requesting a
waiver of the FMNP regulatory
requirement for three-year
agreements contained in 7 CFR
Part 248.10(b)(7)?

Yes ☐

No ☐
If Yes, please provide a The State agency shall ensure that all participating farmers’
description of the regulatory markets enter into written agreements with the State agency.
requirement: The agreement shall be signed by a representative who has
legal authority to obligate the farmer, farmers’ market and/or
roadside stand … Agreements may not exceed 3 years.
2. Is your State agency making the
Yes ☐
request because your State
FMNP cannot meet the
program’s regulatory
requirement due to COVID-19?
No ☐
If Yes, please explain: Click or tap here to enter text.
3. Is the waiver necessary to
provide assistance to FMNP
recipients?

Yes ☐

No ☐
If Yes, please explain: Click or tap here to enter text.
**For Regional Office Use ONLY **
Click or tap here to enter text.
FNS Regional Office Analysis:
(please include a description of any TA
provided to the SA and/or additional
important details about the SA that
would impact consideration of this
request)

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E. Waiver Request Details - Waiver Request for 7 CFR 248 (other)
“Yes” answers are required for Questions 1-3, along with all additional information requested below, for
FNS to consider your State agency’s waiver request. Please submit one waiver request per page. If
additional waiver requests are needed, please copy and paste this table on additional pages.
1. Is your State agency requesting a
waiver(s) of a FMNP regulatory
requirement contained in 7 CFR
Part 248?

Yes ☐

No ☐
If Yes, please provide the Click or tap here to enter text.
regulatory citation(s) and a
description of the regulatory
requirement:
2. Is your State agency making the
request because your State
FMNP cannot meet the
program’s regulatory
requirement due to COVID-19?

Yes ☐

No ☐
If Yes, please explain: Click or tap here to enter text.
3. Is the waiver necessary to
provide assistance to FMNP
recipients?

Yes ☐

No ☐
If Yes, please explain: Click or tap here to enter text.
**For Regional Office Use ONLY **
Click or tap here to enter text.
FNS Regional Office Analysis:
(please include a description of any TA
provided to the SA and/or additional
important details about the SA that
would impact consideration of this
request)

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F. Waiver Request Details - Waiver Request for 7 CFR 248 (other)
“Yes” answers are required for Questions 1-3, along with all additional information requested below, for
FNS to consider your State agency’s waiver request. Please submit one waiver request per page. If
additional waiver requests are needed, please copy and paste this table on additional pages.
4. Is your State agency requesting a
waiver(s) of a FMNP regulatory
requirement contained in 7 CFR
Part 248?

Yes ☐

No ☐
If Yes, please provide the Click or tap here to enter text.
regulatory citation(s) and a
description of the regulatory
requirement:
5. Is your State agency making the
request because your State
FMNP cannot meet the
program’s regulatory
requirement due to COVID-19?

Yes ☐

No ☐
If Yes, please explain: Click or tap here to enter text.
6. Is the waiver necessary to
provide assistance to FMNP
recipients?

Yes ☐

No ☐
If Yes, please explain: Click or tap here to enter text.
**For Regional Office Use ONLY **
Click or tap here to enter text.
FNS Regional Office Analysis:
(please include a description of any TA
provided to the SA and/or additional
important details about the SA that
would impact consideration of this
request)

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G. If the waiver request(s) are approved by USDA FNS, does the FMNP State agency agree to,
not later than 1 year after the date such State agency receives the waiver, submit a report
to the USDA FNS Regional Office which includes:
1. A summary of the use of such waiver(s) by the State agency?

Yes ☐
No ☐

2. A description of whether such waiver(s) resulted in improved
services to FMNP recipients?

Yes ☐
No ☐

Note: The State agency must affirmatively agree to the above elements for FNS to consider the exemption
request.
H. Signature and Date

Typing your first and last name here constitutes your signature.
Click or tap to enter a date.
By signing this document electronically, you verify that the information provided above, as well as any
attachments, are complete and correct.

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