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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.  You must fill out a separate request form for each Recipient Agency (RA) requesting a waiver.

Enter the school year to which this exemption request applies.
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, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted 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; or
  2. fax:
    (833) 256-1665 or (202) 690-7442; or
  3. email:
    program.intake@usda.gov

 

This institution is an equal opportunity provider.

Click here for Nondiscrimination Statement translations.

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