Appendix G - Waiver Request Templates

OMB Number: 0584-0654
Expiration Date: 01/31/2022

Appendix G
CHILD NUTRITION PROGRAM
STATE WAIVER REQUEST TEMPLATE

This information is being collected to assist the Food and Nutrition Service (FNS) ensure States and eligible providers meet the statutory requirements at
Section 12(l) of the Richard B. Russell National School Lunch Act (NSLA) (42 U.S.C. 1760(l)) when requesting a waiver of Child Nutrition Program
(CNP) requirements. This collection is required to obtain a waiver approval under waiver authority at Section 12(l) of the NSLA; FNS uses the
information to evaluate whether waiver requests meet the statutory requirements established at Section 12(l) of the NSLA, assess a state or eligible service
provider’s need to waive program requirements, enhance integrity in CNPs, and monitor the impact waiver approvals have on CNP operations. This
collection does not request any personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided
by law. 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 review this waiver request template, develop a waiver request, and submit a waiver request to FNS is 1 hour per response. 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 22314 ATTN: PRA
(0584-0654). Do not return the completed form to this address.

CHILD NUTRITION PROGRAM
STATE WAIVER REQUEST TEMPLATE
Child Nutrition Programs are expected to be administered according to all statutory and
regulatory requirements; waivers to the requirements are exceptions. However, Section
12(l) of the Richard B. Russell National School Lunch Act, 42 U.S.C. 1760(l), provides
authority for USDA to waive requirements for State agencies or eligible service providers
under certain circumstances. When requesting the waiver of statutory or regulatory
requirements for the Child Nutrition Programs (CNPs), including the Child and Adult
Care Food Program (CACFP), the Summer Food Service Program (SFSP), the National
School Lunch Program (NSLP), the Fresh Fruit and Vegetable Program (FFVP), the
Special Milk Program (SMP), and the School Breakfast Program (SBP), State agencies
and eligible service providers should use this template. State agencies and eligible service
providers should consult with their FNS Regional Offices when developing waiver
requests to ensure a well-reasoned, thorough request is submitted. State agencies and
eligible service providers are encouraged to submit complete waiver requests at least 60
calendar days prior to the anticipated implementation date. Requests submitted less than
60 calendar days prior to the anticipated implementation should be accompanied by an
explanation of extenuating circumstances.
For more information on requests for waiving Program requirements, refer to
SP 15-2018, CACFP 12-2018, SFSP 05-2018, Child Nutrition Program Waiver Request
Guidance and Protocol- Revised, May 24, 2018.
1. State agency submitting waiver request and responsible State agency staff contact
information:
2. Region:
3. Eligible service providers participating in waiver and affirmation that they are
in good standing:
4. Description of the challenge the State agency is seeking to solve, the goal of the
waiver to improve services under the Program, and the expected outcomes if the
waiver is granted. [Section 12(l)(2)(A)(iii) and 12(l)(2)(A)(iv) of the NSLA]:
5. Specific Program requirements to be waived (include statutory and regulatory
citations). [Section 12(l)(2)(A)(i) of the NSLA]:
6. Detailed description of alternative procedures and anticipated impact on
Program operations, including technology, State systems, and monitoring:

SP 15-2018, CACFP 12-2018, SFSP 05-2018
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7. Description of any steps the State has taken to address regulatory barriers at the
State level. [Section 12(l)(2)(A)(ii) of the NSLA]:
8. Anticipated challenges State or eligible service providers may face with the
waiver implementation:
9. Description of how the waiver will not increase the overall cost of the Program to
the Federal Government. If there are anticipated increases, confirm that the
costs will be paid from non-Federal funds. [Section 12(l)(1)(A)(iii) of the NSLA]:
10. Anticipated waiver implementation date and time period:
11. Proposed monitoring and review procedures:
12. Proposed reporting requirements (include type of data and due date(s) to FNS):
13. Link to or a copy of the public notice informing the public about the proposed
waiver [Section 12(l)(1)(A)(ii) of the NSLA]:
14. Signature and title of requesting official :
________________________________________________________
Title:
Requesting official’s email address for transmission of response:
TO BE COMPLETED BY FNS REGIONAL OFFICE:
FNS Regional Offices are requested to ensure the questions have been adequately addressed by
the State agency and formulate an opinion and justification for a response to the waiver request
based on their knowledge, experience and work with the State.
Date request was received at Regional Office:
Check this box to confirm that the State agency has provided public notice in
accordance with Section 12(l)(1)(A)(ii) of the NSLA
x

Regional Office Analysis and Recommendations:

SP 15-2018, CACFP 12-2018, SFSP 05-2018
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