Request For Approval Of One-Time Exception - Arizona Department Of Education

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Request for Approval of One-Time Exception

Date of

Claim

Program:

Claim PY:

Request:

Month:

Sponsor:

CTD:

7 CFR 225.9 (d)(6) states

"A final Claim for Reimbursement shall be submitted to the State Agency not later than

60 days following the last day of the full month covered by the claim."

However, if you failed to meet this requirement you may be granted an exception for a single month's claim if a similar

exception has not been granted during the previous 36-month period.

To request your exception, complete this form

ELECTRONICALLY

and have an

AUTHORIZED

HNGrantsManagement@azed.gov

REPRESENTATIVE

submit this form

VIA E-MAIL

Describe the problem contributing to the lateness of the claim.

Provide a Corrective Action Plan detailing changes made to the claims process that will eliminate future late claims.

As the Authorized Representative submitting this form via E-mail, I certify that I am a Governing Board Member that is listed on the Certification

Page of the ADE Food Program Permanent Service Agreement Contract; or a Designated Official/Authorized Representative that is listed on the last

page of the ADE Food Program Permanent Service Agreement Contract for the above named 'SPONSOR'. I understand by sending this document I am

certifying that: 1) the lateness of the above recorded claim was within SPONSOR's control; 2) SPONSOR has NOT been granted a similar exception

during the previous 36-month period; 3) SPONSOR understands another exception will NOT be granted for a 36-month period; 4) that all the above

recorded information is true and accurate; and 5) that the above recorded Corrective Action Plan will be implemented prior to the receipt of exception

funds.

1535 West Jefferson Street, Bin #7, Phoenix, Arizona 85007 • (602) 542-8700 •