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["COMBINED WAIVER REQUEST FORM                                                                                                                                                                                                                                                                                                                                                                                                                           (Applicable to both the CACFP and SFSP)"]
["Form Instructions: Please carefully complete the required information below if requesting a waiver of any of the following: (1) meal times; (2) non-congregate feeding; (3) monitoring requirements; (4) on-site monitoring; (5) the (60) day claim submission deadline for January or February 2020 claims; and/or (6) Food Service Management Company (FSMC) Waiver for SFSP vended meals only. When selecting the waiver(s) you wish to request in Part III, please utilize the drop-down menu provided.  Once the form has been completed, review it for accuracy, and send it to Leslie Truman at Leslie.Truman@decal.ga.gov.                                                                                                                                                                                                                    Note (SFSP sponsors only)*: To be approved for a waiver, you must first have an approved CACFP or SFSP application. For questions concerning SFSP and/or CACFP application approval, please e-mail your assigned Application Specialist. "]
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["PART I: Preliminary Information"]
["Organization Name:"]
["Agreement Number:"]
["Number of Actual Sites under Waiver:"]
["Today's Date:"]
["PART II: Meal Distribution Method: (Check ALL that apply)"]
["Individual Meals","Multiple Meals","Parent Pick-Up (Requires additional completion of Parent Pick up Waiver Form)    ","Meal Delivery (CACFP/SFSP Home meal delivery requires certification response) ",null,"FOR HOME MEAL DELIVERY ONLY: By clicking \"yes\" below, I certify that as a CACFP/SFSP Program operator, I will:\n(1) first obtain written consent from households of eligible & enrolled children and/or adult participants that the household wants to receive delivered meals; \n(2) confirm the number of children/adults being served;  \n(3) confirm the household's current contact information to ensure meals are delivered to the correct location; \n(4) ensure not to exceed the maximum number of meals per child per day; and\n(5) ensure meals will only be served/delivered to children who are in area eligible locations or who are eligible for free or reduced price meals (closed-enrolled) (for SFSP Sponsors only).  \nAdditionally, I certify that I will notify households if their contact information will be shared with any external organization. Households also must have a way of notifying the sponsor of the need for individual substitutions due to medical or other special dietary needs. (Note: Written consent may be issued by e-mail or other electronic means and must be given by the participant's parent or guardian.)  "]
["PART III: Waiver Selection and Justification of Need"]
["Select Waiver Request",null,null,null,null,"Waiver Start Date","Written Justification for Request (In detail, explain why this waiver is needed.)"]
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["Certification Statement:\nI certify that the information contained within this entire document is true and correct to the best of my ability and that intentionally listing false or inaccurate information and/or failure to notify DECAL when the information contained in this document changes, may result in the denial of a claim(s) for reimbursement and/or termination and disqualification of the organization, its responsible principals and/or responsible individuals from participation in the CACFP, SFSP, or any other Child Nutrition Program (CNP). "]
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["Electronic Signature of Program Contact or Authorized Representative: /s/   [TYPE YOUR NAME HERE]"]

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["CACFP Meal Time Waiver"]
["CACFP Non-Congregate Feeding Waiver"]
["CACFP On-site Monitoring"]
["SFSP FSMC Waiver (Vended Meals Only)*"]
["SFSP Meal Time Waiver*"]
["SFSP Monitoring Requirements*"]
["SFSP Non-Congregate Feeding Waiver*"]
["SFSP On-site Monitoring*"]
["Claim Submission – February 2020 Claim "]
["Claim Submission - January 2020 Claim"]