Request for Exemption from the School Meals Whole Grain
Rich Requirement for School Year 2014-2015 & 2015-2016
USDA Memo SP 20-2015 allows Sponsors the ability to request an exemption from the school meals whole grain rich requirement
for SY 2014-15 & 2015-16, upon KSDE approval. Sponsors must submit this form to request an exemption. Approvals are valid
through school year 2015-2016. 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 exemptions through SY 2015-16 and do not need to reapply for the pasta 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
Sponsor Number:
KSDE CNW
USE ONLY
Product*
Reasons for requesting flexibility
(check all that apply)
Name:
Financial hardship
Manufacturer:
Limited product availability
 Approved
 Denied
Sponsor Name:
Product code:
Explanation/Documentation (may attach
records, photos, invoices to support)
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 Signature
Email
Date
Food Service Director Signature
Email
Date
Email or mail request form and supporting documentation to Kelly Chanay at kchanay@ksde.org or
Child Nutrition & Wellness, Kansas State Department of Education
900 SW Jackson Street, Ste. 251, Topeka, Kansas 66612
USDA is an equal opportunity provider and employer.
Child Nutrition & Wellness, Kansas State Department of Education
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Part 4: Justification for Request – Additional Products
KSDE CNW
USE ONLY
Product
Name:
 Approved
Manufacturer:
Reasons for requesting flexibility
(check all that apply)
Explanation/Documentation (may attach
records, photos, invoices to support)
Financial hardship
Limited product availability
Unacceptable product quality
 Denied
Product code:
Poor student acceptability
Other:
KSDE CNW
USE ONLY
Product
Name:
 Approved
Manufacturer:
Reasons for requesting flexibility
(check all that apply)
Explanation/Documentation (may attach
records, photos, invoices to support)
Financial hardship
Limited product availability
Unacceptable product quality
 Denied
Product code:
Poor student acceptability
Other:
KSDE CNW
USE ONLY
Product
Name:
 Approved
Manufacturer:
Reasons for requesting flexibility
(check all that apply)
Explanation/Documentation (may attach
records, photos, invoices to support)
Financial hardship
Limited product availability
Unacceptable product quality
 Denied
Product code:
Poor student acceptability
Other:
KSDE CNW USE ONLY
Reviewed By:
Date:
Comments:
Child Nutrition & Wellness, Kansas State Department of Education
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