8/2019
CCFP Waiver Request Form
Name of Emergency Event:____________________ Date of Event: __________
Authorization Number: ________ Name of Contractor: ______________________
Use this form if your organization has experienced problems and would like to request a waiver that allows your
organization to not follow certain Child Care Food Program requirements for a specific period of time or until condition is
corrected. Sufficient reason is required for each request. We will let you know if your waiver request is approved and for
what time period or if additional information is required.
If you are a multi-site contractor, specify the names of sites for which the waiver is requested. Attach other
sheets, if needed.
_____1. Unable to file claim(s) within 60 days of the end of the claim month (Attach paper claim for month(s) affected)
List reason(s) for requesting this waiver:
_____________________________________________________________________________________
_____2. Unable to provide milk with meals due to milk unavailability for the specified period of time
Specify the month(s) and date(s) that milk was unavailable:
_____________________________________________________________________________________
_____3. Unable to meet other meal pattern requirements (excluding milk)
Specify the month(s) and date(s) that meals did not meet meal pattern requirements and include reasons meal
items were not available:
_____________________________________________________________________________________
_____4. Catered sites – unable to get catered meals as usual, therefore purchased and served other foods. These site(s)
had local health department approval to serve these meals
Specify the period of time requested:
_____________________________________________________________________________________
_____5. Unable to approve free and reduced-price meal applications and/or update enrollment roster
List reason(s) and time period requested for this waiver:
_____________________________________________________________________________________
_____6. Sponsors - unable to meet monitoring deadlines for new sites approved to start
List reason(s) and month(s) that you are requesting this waiver:
_____________________________________________________________________________________
_____7. Other request(s) for waiver: _______________________________________________________
List reason(s) that you are requesting this waiver:
_____________________________________________________________________________________
_____________________________________________________________________________________
Submitted by: ____________________________ Date: ________________________
Title: ___________________________________ Return to:
Department of Health
Phone Number: __________________________ Bureau of Child Care Food Programs
4052 Bald Cypress Way, Bin A-17
County: ________________________________ Tallahassee, FL 32399-1727
