Appendix G State Waiver Request Form

Appendix G: State Waiver Request form

OMB 0584-0083
Exp xx/xx/xxxx

STATE WAIVER REQUEST
1.

Waiver Serial Number (if applicable):

2.

Type of request:

3.

Regulatory citation(s):

4.

State:

5.

Region:

6.

Regulatory requirements:

7.

Description of alternative procedures:

8.

Justification for request:

9.

Anticipated impact on households and State agency operations:

10. Caseload information, including percent, characteristics, and quality control
error rate for affection portion (if applicable):
11. Anticipated implementation date and waiver approval period:
12. Proposed quality control review procedures:
13. Signature and title of requesting official:
________________________________________________________
Title:
Email for transmission of response:
14. Date of request:
15. State agency staff contact (name/email/telephone):
16. Regional Office contact person (to be completed by FNS Regional Office):
This information is being collected to assist the Food and Nutrition Service in organizing and tracking new and
existing waiver requests. This is a voluntary collection and FNS uses the information to
monitor program changes and expiration dates. 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
0584-0083. The time required to complete this information collection is estimated to average one hour 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 Rev 10/2014
Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22306 ATTN: PRA
(0584-0083). Do not return the completed form to this address.