Program Year 2021 Meal Distribution Waiver Usage Intake for NSLP and CACFP

COVID-19 Meal Distribution Waiver

Initial Notification
Please complete and submit this form to notify TDA of the CE’s intention to use one or more of the following nationwide waivers for all programs:
- Non-congregate Service Waiver
- Alternative Mealtime Waiver
- No Child Present, Parent Pick Up Waiver
- Offer Versus Serve (OVS) Requirement for National School Lunch Program (NSLP) Senior High Schools only
For additional guidance on completing this waiver, see the COVID-19 Waiver located on www.Squaremeals.org/FandNResources/CoronavirusUpdateforContractingEntities.aspx

Attestation Statement
Click on the calendar icon to confirm today's date. *

MonthDayYear
MM-DD-YYYY
Note: Only CE staff may submit this form. A food service management company (FSMC) staff member cannot submit this form on behalf of the CE or attest to its accuracy.
Contracting Entity (CE) Name*
CE Name exactly as it appears in TX-UNPS
CE Identification Number (CE ID)*
5-digit number assigned by TDA in TX-UNPS
Check each of the following statements as true:*

I am an Authorized Representative (AR) of the Contracting Entity (CE) listed on the "FND-101, CERTIFICATE of AUTHORITY for EXTERNAL USERS" or "FND-135, USER ACCESS MANAGER FORM" that has been approved by TDA prior to this submission of this waiver notification.I certify that the CE has retained documentation related to the information submitted in this request for all meals served and claimed under this waiver. This includes, but is not limited to counting and food production records.I understand that it is the CE's RESPONSIBILITY TO IMPLEMENT THESE WAIVERS IN COMPLIANCE WITH ALL APPLICABLE REGULATIONS and that NON-COMPLIANCE MAY RESULT IN ADVERSE AND/OR FISCAL ACTION.
Name of person attesting to the information on this form:*

First NameLast Name
Each party acknowledges and agrees that this information in this form is attested by the name entered in the above field and shall be considered as an original signature for all purposed and shall have the same force and effect as an original signature.
Title of Authorized Representative*
CE Phone Number*
Enter the email for the authorized representative:
example@example.com
Alternate Email Address
example@example.com
Email address for Superintendent/Sponsoring Official/Administrator
Enter email address if different than the Confirmation Email
Email address for Child Nutrition Director (CND)
Enter email address if different than the Confirmation Email
Select the Submit button to send this form to TDA.
- It may take a few minutes for the form to submit depending on your connection speed.
- You will see a confirmation message when the submission is complete.
- Please click the Submit button only once.
After you submit the form, you will receive a confirmation email message which includes a copy of your submitted responses. This confirmation email with the copy of submitted responses must be retained by the CE.
Please check after you have made the requested corrections.

I have corrected the necessary fields.
FOR TDA INTERNAL USE ONLY
TDA Review

CE name does not match the name on the application in TX-UNPSCE ID is incorrectAuthorized Representative cannot be verified in TX-UNPSAn employee from an FSMC cannot submit or attest to the waiver
Should be Empty:

COVID-19 Meal Distribution Waiver

INITIAL WAIVER NOTIFICATION

Part I: General Information

Part II. Operational Information

Attestation Statement