Fiscal Waiver Template_1810-0760

This template is an example that may be used for the submission of a request for waivers of
certain fiscal requirements under the Elementary and Secondary Education Act of 1965, as
amended. Note that a State educational agency is not required to use this template; for
assistance, please contact [email protected].

The Honorable Ian Rosenblum
Deputy Assistant Secretary for Policy and Programs,
Delegated the authority to perform the functions and
duties of the Assistant Secretary
Office of Elementary and Secondary Education
U.S. Department of Education
400 Maryland Avenue, SW
Washington, DC 20202
Dear Deputy Assistant Secretary Rosenblum:
I am writing to request a waiver, pursuant to section 8401 of the Elementary and Secondary
Education Act of 1965 (ESEA), of the following requirements as a result of ongoing challenges
related to the novel Coronavirus Disease 2019 (COVID-19):
State:
Please check all that apply:
 Carryover limitation in section 1127(b) of the Elementary and Secondary Education Act
of 1965 (ESEA) for Federal fiscal year (FY) 2020 Title I, Part A funds (i.e., the Title I,
Part A funds that will become carryover funds on October 1, 2021): to waive the
requirement that limits an SEA’s ability to grant to its LEAs a waiver of the 15 percent
Title I, Part A carryover limitation in section 1127(a) to once every three years.
Period of availability of funds in section 421(b) of the General Education Provisions Act
(GEPA): to extend the period of availability of FY 2019 funds for programs in which the
SEA participates under its approved consolidated State plan until September 30, 2022. The
programs are (please check all that apply):
 Title I, Part A of the ESEA (Improving Basic Programs Operated by LEAs),
including the portions of the SEA’s Title I, Part A award used to carry out section
1003 school improvement, section 1003A direct student services, if applicable, and
Title I, Part D, Subpart 2
 Title I, Part B of the ESEA (State Assessment Formula Grants)
 Title I, Part C of the ESEA (Education of Migratory Children)
 Title I, Part D, Subpart 1 of the ESEA (Prevention and Intervention Programs for
Children and Youth Who Are Neglected, Delinquent, or At Risk)
 Title II, Part A of the ESEA (Supporting Effective Instruction)

 Title III, Part A of the ESEA (English Language Acquisition, Language
Enhancement, and Academic Achievement)
 Title IV, Part A of the ESEA (Student Support and Academic Enrichment Grants)
 Title IV, Part B of the ESEA (21st Century Community Learning Centers)
 Title V, Part B, Subpart 2 of the ESEA (Rural and Low-Income School Program)
 McKinney-Vento Education for Homeless Children and Youth Program
I am requesting this/these waiver(s) because it is not possible to obligate funds on a timely and
responsible basis.
Consistent with the requirements of ESEA section 8401(b)(1)(C) and (F), describe how the
waiving of such requirements will advance student academic achievement and how schools will
continue to provide assistance to the same populations served by programs for which waivers
are requested.
Enter description here.

In seeking these waivers, I assure that (please check all assurances):
 The SEA will use, and ensure that its subgrantees use, funds under the respective
programs in accordance with the provisions of all applicable statutes, regulations,
program plans, and applications not subject to these waivers.
 The SEA will work to mitigate, and ensure that its subgrantees work to mitigate, any
negative effects that may occur as a result of the requested waivers.
 The SEA has provided the public and all LEAs in the State with notice of, and the
opportunity to comment on, this request by posting information regarding the waiver
request and the process for commenting on the State website in the manner in which the
SEA customarily provides such notice and opportunity to comment and has enclosed with
this waiver request any comments received and a description of how the SEA addressed
such comments.

Thank you for your consideration.
Sincerely,
Chief State School Officer (or Authorized
Representative)
Digital Signature
OR
Typed Name and Date
By typing my name here, I am affirming submission
of this waiver on behalf of the State.

OMB Number: 1810-0760
Expiration Date: xx/xx/xxxx
Public Burden Statement: According to the Paperwork Reduction Act of 1995, no persons
are required to respond to a collection of information unless such collection displays a valid
OMB control number. The valid OMB control number for this information collection is
1810-0760. Public reporting burden for this collection of information is estimated to
average 1 hour per response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. The obligation to respond to this collection is voluntary. If you
have any comments concerning the accuracy of the time estimate, suggestions for improving
this individual collection, or if you have comments or concerns regarding the status of your
individual form, application or survey, please contact the Office of School Support and
Accountability, 400 Maryland Avenue, SW, LBJ Federal Office Building, Washington, DC,
20202 or [email protected].