State Agency 180-Day Waiver Request Form

State Agency 180-Day Waiver Request Form
Use this form to request a 180-day waiver from a state agency and provide the details and documents needed for review.
Applicant Information
Full Name
First NameMiddle NameLast Name
Organization or Agency Name
Job Title / Role
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Waiver Request Details
State agency or department name
Program, service, or application name / reference number
Type of waiver requested
Reason for 180-day waiver request
Requested start date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Requested end date or confirmation of 180-day waiver
Special circumstances or supporting explanation
Supporting Materials and Review Acknowledgment
Supporting Documents
Cancelof
Additional Information / Internal Notes
Should be Empty: