Fillable Meal Pattern Flexibility Request Ver040920 Covid (Mississippi)

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Meal Pattern Flexibility Request Ver040920 Covid (Mississippi)

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Meal Pattern Flexibility Request
District/Sponsor Name: _______________________________________________________________
Contact Name: _____________________________________ Contact Number: _________________
Applicable meal pattern? CACFP SFSP-Unanticipated School Closures NSLP
Component(s) not available (list):
Description of efforts to obtain component(s)
Time period component(s) expected to be unavailable:
_____________________________________
Proposed substitute(s) for component(s)
Sites Impacted
Expected cost impact of substitution: ________________ Increase Decrease Neither
NOTE: You must maintain all documentation related to the substitution, including documentation of
efforts to procure the component(s), and actual cost impact documentation. This documentation will be
collected by the State Agency when the unanticipated school closures feeding program ends.
STATE AGENCY USE ONLY
Approved by: _________________________________________________
Date Approved:
______________________
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Meal Pattern Flexibility Request Ver040920 Covid (Mississippi)

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Completed 16 July 2020

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