Alternate Meal Service Time Approval Request Form

Instructions: Complete the following Alternate Meal Service Time Approval Request form if meals were served outside of the approved meal service time due to an unanticipated event that is outside of the sponsor’s control. These events include, but are not limited to: delayed meal deliveries, inclement weather that delays the start of the meal service, delayed public transportation utilized by participants, and other incidents as deemed appropriate by the state agency. This request must be submitted and approved by DPI prior to submitting the affected SFSP claim.

1. Sponsor Contact Information regarding this Alternate Meal Service Time Request *This question is required.

Sponsor Name
Agency Code
First and Last Name
Email Address
Site Name

2. Date of Alternate Meal Service Time *This question is required. This question requires a valid date format of MM/DD/YYYY.

mm/dd/yyyy calendar

3. Meal Type and Time *This question is required.Select the meal type that was served outside of the approved meal period and report the actual time the meal/snack was served (i.e., 12:30 - 1:00 pm).

Breakfast Please enter an 'other' value for this selection.
Lunch Please enter an 'other' value for this selection.
Supper Please enter an 'other' value for this selection.
Snack Please enter an 'other' value for this selection.

4. Briefly describe the reason meals were served outside of the approved meal service time. *This question is required.

5. Additional comments, if needed.

6. Certification: *This question is required.I certify that the meals served followed the SFSP requirements, with the exception of not being served during the approved meal service time. This includes, but is not limited to:

• providing complete reimbursable meals, meals are supported with proper documentation, such as a menu, production records, and invoices,

• meals are counted at the point of service, and

• meals are served according to State and local health, safety, and sanitation standards.

DPI will review this request for approval and notify the contact person listed above via email. DPI has the authority to disallow the meals if the sponsor does not notify DPI of the time change and/or it is determined that not all Program requirements have not been met.

Clear

Signature of

Date completed: 04/29/2026, 10:19 pm (EST)