Sample Petition for Waiver
481 -- 6.17 (10A,17A, ExecOrd11) Sample petition for waiver or variance
BEFORE THE DEPARTMENT OF INSPECTIONS AND APPEALS
Petition by (insert the name of petitioner):
for the waiver of (insert rule citation):
relating to (insert the subject matter).
PETITION FOR WAIVER
Include the following information in the petition for waiver where applicable and known:
- Provide the petitioner’s (the person that is asking for the waiver or variance) name, address and telephone number.
- Describe and cite the specific rule from which a waiver or variance is requested.
- Describe the specific waiver or variance requested, include the exact scope and time period that the waiver or variance will extend.
- Explain the important facts that the petitioner believes justify the waiver or variance. Include in your explanation
- (a) why application of the rule would pose an undue hardship to the petitioner;
- (b) why granting the waiver or variance would not prejudice the substantial legal rights of any person;
- (c) state whether the provisions of a rule subject to this petition are specifically mandated by statute or another provision of law; and
- (d) state whether public health, safety and welfare will be affected if the requested waiver or variance is granted.
- Provide history of prior contacts between the department and the petitioner relating to the regulated activity, license, audit, investigation, inspection or representation that would be affected by the waiver or variance. In that history, include a description of each affected regulated activity, license, appeal, hearing, audit, investigation, inspection, representation or other assigned function of the department, any notices of violation, contested case hearings, or investigative reports relating to the regulated activity, license, appeal, hearing, audit, investigation, inspection, representation or other assigned function of the department within the last five years.
- Provide information known to the petitioner regarding the department's treatment of similar cases.
- Provide the name, address and telephone number of any public agency or political subdivision which also regulates the activity in question, or which might be affected by the grant of a waiver or variance.
- Provide the name, address and telephone number of any person or entity that would be adversely affected or disadvantaged by the grant of the waiver or variance.
- Provide signed releases of information authorizing persons with knowledge regarding the request to furnish the department with information relevant to the waiver or variance.
I hereby attest to the accuracy and truthfulness of the above information.
(Petitioner's signature) (Date)