**Copy of NSCHC Waiver Request Form**

**Updated 10/19/2022**

**For informational purposes only, not for submission. Formal NSCHC waiver requests must be submitted using the AmeriCorps online form, available****here****. Contact****NSCHCWaiverRequest@cns.gov****for assistance.**

Effective May 1, 2021, AmeriCorps may waive provisions of NSCHC for good cause, or for any other lawful basis (45 CFR §2540.207). AmeriCorps grant recipients may submit a waiver request to NSCHCWaiverRequest@cns.gov. Only prime grant recipients may apply for a waiver. Subrecipients may submit a request to the sponsoring prime grant recipient. Review the instructions carefully and submit this completed form. Grant recipients will receive notification from AmeriCorps regarding the determination of this request. If approved, AmeriCorps will identify the effective start and end dates for the waiver. Waivers may not be applied retroactively to any NSCHC that were completed prior to receiving the waiver approval. Please review the AmeriCorps NSCHC Manual and FAQs for information regarding existing requirements. 

Instructions: 

1. Please complete and submit the form in its entirety. 

2. Please indicate if supplemental documentation related to this waiver request has been sent to NSCHCWaiverRequest@cns.gov. If supplemental documentation has been provided via email, please ensure the email subject line is clearly described within this form (see example below). AmeriCorps will not be responsible for reviewing email documentation submissions that do not clearly identify this specific waiver request. 

· Email Subject Line: NSCHCWAIVER_GRANT NUMBER_DATE OF SUBMISSION XX/XX/XXXX 

3. If you need technical assistance, email NSCHCWaiverRequest@cns.gov. This email is monitored daily by AmeriCorps staff and a response will be provided within 1-3 business days

Upon receipt of this information, we will review and respond to your request. Additionally, please know that NSCHC waiver requests must be submitted by AmeriCorps prime grant recipients, on behalf of their subrecipient grantees.

**Copy of Online Form Sections**

AmeriCorps Grant Recipient Certification: 

Acknowledge the following terms by indicating "Yes". The Waiver request will be denied if the terms are not acknowledged with a "Yes". 

1. I understand that NSCHC files may be found noncompliant if the terms of an approved waiver are not followed. Noncompliance can result in enforcement actions, such as cost-based disallowance. 

Choose an item.

2. I understand that NSCHC files may be found noncompliant if the recipient does not follow all other applicable NSCHC compliance requirements. Noncompliance can result in enforcement action, such as cost-based disallowance. 

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AmeriCorps Grant Recipient Submitting Individual 

3.Submitted by (First and Last Name)

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4.Submitter Phone

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5.Submitter Email

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6.Submitter Position Title

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7.Name of AmeriCorps Portfolio Manager

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Grant Program Information 

Reminder: Only prime grant recipients may apply for a waiver. Subrecipients may submit a request to the sponsoring prime grant recipient. AmeriCorps will not accept Waiver Request Forms received by subrecipients. 

8.Prime Grant Number

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9.Legal Organization Name

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10.EIN Number

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11.UEI (Unique Entity Identifier)

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12.Does this Waiver request apply to subrecipient(s)?

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13. If this Waiver requests applies to subrecipient(s), provide subrecipient grant number(s).

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Waiver Request Details

Reminder: Only prime grant recipients may apply for a waiver. Subrecipients may submit a request to the sponsoring prime grant recipient. AmeriCorps will not accept Waiver Request Forms received by subrecipients. 

14.Waiver is requested from the following NSCHC provisions:

*Select all that apply. Note: If you select "Other", list details of the specific issue for which you are seeking a waiver.*

§2540.200: Which entities are required to comply with the National Service Criminal History Check requirements in this part?

§2540.202: What eligibility criteria apply to an individual for whom a National Service Criminal History Check is required? 

§2540.203: May a grant recipient or subrecipient or service site establish and apply suitability criteria for individuals to work or serve in a position specified in §2540.201(a)?

§2540.204: What are the components of a National Service Criminal History Check?

§2540.205: By when must the National Service Criminal History Check be completed?

§2540.206: What procedural steps are required, in addition to conducting the National Service Criminal History Check described in 2540.204?

Other

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15.Describe the Waiver request in the text field below. The request should address the following:

a. Brief description of project/program (must include location and service activities of any recipients/subrecipient included in this request) 

b. Explain why the NSCHC requirement/s cannot be met. Be specific about which elements of the requirements would vary from current policy. **If the request pertains only to specific individuals, please provide their first and last names.**

c. Describe the proposed alternative process to the NSCHC. 

d. Explain how the program will employ methods to ensure safety of the beneficiaries (beyond NSCHC compliance requirements).

e. Provide any additional information relevant to explaining the reason for your request. 

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16.Does this Waiver request have supplemental documentation that was emailed to NSCHCWaiverRequest@cns.gov?

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17.If yes, provide email Subject Line used to send supplemental documentation related to this Waiver request. 

*NOTE: AmeriCorps will not be responsible for reviewing email documentation submissions that do not clearly identify this specific waiver request.*

· *Format for email Subject Line: NSCHCWAIVER_GRANT NUMBER_DATE OF SUBMISSION XX/XX/XXXX*

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18. Have you reviewed your responses and are they complete?

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AmeriCorps will review this request and notify grant recipients of the response determination and, if applicable, requests for clarification. Please allow 1-3 business days for a response. 

**Copy of NSCHC Waiver Request Form**

**For informational purposes only, not for submission. Formal NSCHC waiver requests must be submitted using the AmeriCorps online form, available****here****. Contact****NSCHCWaiverRequest@cns.gov****for assistance.**

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