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Breakfast After the Bell Waiver Request

Please Note

Schools that obtain approved waiver requests are not eligible to receive grant funding.

Contact Information
Date
Request Information

We hereby submit the following request for exemption from the Breakfast After the Bell requirements set forth in the New York State Education Law.  This exemption request applies to the 2018-2019 school year.  You must fill out a separate request form for each Recipient Agency (RA) requesting a waiver.

You must provide written justification or other documented evidence (e.g., cost analysis, meal count records, production records) to demonstrate the lack of need and/or economic hardship.
Will you be submitting more substantiating documentation to the Child Nutrition mailbox? This is not required if the written justification is sufficient.
Attestation
, as the duly authorized representative of

do hereby attest that the aforementioned SFA and all schools under its jurisdiction operating the the School Breakfast Program authorized under the Child Nutrition Act of 1966 (42 U.S.C. 1773), are in compliance with the waiver request requirements set forth in Section 4 of Chapter 537 of the Laws of 1976.

I certify that all information in this waiver request is true and correct, and I understand that if the SED CNP Administration determines the SFA or the RA to be noncompliant with one or more of the requirements set forth in CNP laws, regulations,guidance and policy, the waiver request may be denied or terminated and the SFA may be subject to fiscal sanctions.

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USDA Nondiscrimination Statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. 

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)     mail: U.S. Department of Agriculture
         Office of the Assistant Secretary for Civil Rights
         1400 Independence Avenue, SW
         Washington, D.C. 20250-9410;

(2)     fax: (202) 690-7442; or

(3)     email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Los demás programas de asistencia nutricional del FNS, las agencias estatales y locales, y sus beneficiarios secundarios, deben publicar el siguiente Aviso de No Discriminación:

De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y políticas de derechos civiles del Departamento de Agricultura de los EE. UU. (USDA, por sus siglas en ingles), se prohíbe que el USDA, sus agencias, oficinas, empleados e instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo, discapacidad, edad, o en represalia o venganza por actividades previas de derechos civiles en algún programa o actividad realizados o financiados por el USDA.

Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa (por ejemplo, sistema Braille, letras grandes, cintas de audio, lenguaje de seas americano, etc.), deben ponerse en contacto con la agencia (estatal o local) en la que solicitaron los beneficios. Las personas sordas, con dificultades de audición o discapacidades del habla pueden comunicarse con el USDA por medio del Federal Relay Service [Servicio Federal de Retransmisión] al (800) 877-8339. Además, la información del programa se puede proporcionar en otros idiomas.

Para presentar una denuncia de discriminación, complete el Formulario de Denuncia de Discriminación del Programa del USDA, (AD-3027) que está disponible en linea en:http://www.ocio.usda.gov/sites/default/files/docs/2012/Spanish_Form_508_Compliant_6_8_12_0.pdf. y en cualquier oficina del USDA, o bien escriba una carta dirigida al USDA e incluya en la carta toda la información solicitada en el formulario. Para solicitar una copia del formulario de denuncia, llame al (866) 632-9992. Haga llegar su formulario lleno o carta al USDA por:

(1)     correo: U.S. Department of Agriculture
         Office of the Assistant Secretary for Civil Rights
         1400 Independence Avenue, SW
         Washington, D.C. 20250-9410;

(2)     fax: (202) 690-7442; o

(3)     correo electrónicoprogram.intake@usda.gov.

Esta institución es un proveedor que ofrece igualdad de oportunidades.

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