Part 1: Justification for Request

The Interim Final Rule: Child Nutrition Program Flexibilities for Milk, Whole Grains, and Sodium Requirements allows Sponsors the ability to request an exemption from the school meals whole grain rich requirement for SY 2018-19, upon KSDE approval. Sponsors must submit this form to request an exemption. Sponsors granted an exemption must continue, at a minimum, to meet the SY 2013-14 whole grain rich requirement (i.e., half of the grains offered required to be whole grain-rich products). Sponsors may retain the previously approved pasta/whole grain rich exemptions through SY 2018-19and do not need to reapply for the pasta/whole grain rich items already approved.

Parts 1-3 must be completed in their entirety. Any incomplete exemption request forms will not be approved and will be returned to the Sponsor.

Part 1: Justification for Request

SponsorNumber: Sponsor Name:
KSDE CNW USE ONLY / Product* / Reasons for requesting flexibility
(check all that apply) / Explanation/Documentation(may attach records, photos, invoices to support)
Approved
Denied / Name:
Manufacturer:
Product code: / Financial hardship
Limited product availability
Unacceptable product quality
Poor student acceptability
Other:

*See Part 4 to request additional product exemptions

Part 2: Whole Grain-Rich Information

Please list the whole grain-rich products that are being used (name, manufacturer and product number) so that a list of acceptable products can be shared with other Kansas Sponsors:

Describe Sponsor’s plan to achieve future compliance with the full whole grain rich requirement once the exemption expires.

What technical assistance or information would be helpful to you as you continue to work on incorporating whole grain-rich products?

Part 3: Signatures

______

Authorized Representative SignatureEmailDate

Food Service Director SignatureEmailDate

Email or mail request form and supporting documentation to Kelly Chanay at or

Child Nutrition & Wellness, Kansas State Department of Education

900 SW Jackson Street, Ste. 251, Topeka, Kansas 66612

This institution is an equal opportunity provider.

Part 4: Justification for Request – Additional Products

KSDE CNW USE ONLY / Product / Reasons for requesting flexibility
(check all that apply) / Explanation/Documentation(may attach records, photos, invoices to support)
Approved
Denied / Name:
Manufacturer:
Product code: / Financial hardship
Limited product availability
Unacceptable product quality
Poor student acceptability
Other:
KSDE CNW USE ONLY / Product / Reasons for requesting flexibility
(check all that apply) / Explanation/Documentation(may attach records, photos, invoices to support)
Approved
Denied / Name:
Manufacturer:
Product code: / Financial hardship
Limited product availability
Unacceptable product quality
Poor student acceptability
Other:
KSDE CNW USE ONLY / Product / Reasons for requesting flexibility
(check all that apply) / Explanation/Documentation(may attach records, photos, invoices to support)
Approved
Denied / Name:
Manufacturer:
Product code: / Financial hardship
Limited product availability
Unacceptable product quality
Poor student acceptability
Other:
KSDE CNW USE ONLY
Reviewed By: / Date:
Comments:

Child Nutrition & Wellness, Kansas State Department of EducationPage 1