Request Waiver

Go through each step below.

Waiver Information

Authorized representative

Full Name Responsible person signing waiver. For example owner, CEO, director, president...

Title

Contact Number

Email Address

The waiver is prepared by the authorized representative

Preparer

Full Name Person filling out and preparing this waiver.

Title

Contact Number

Email Address

Entity Information

Entity Legal Name

Entity D/B/A(s)

Entity Address

Entity City

Entity State

Entity ZIP

Compliancy Information

Request Number Enter the number of times (including this one) that a waiver has been submitted for the identified phone system in this affidavit.

Projected Compliance Date

The projected date (mm/dd/yyyy) for compliance with Kari's Law and Commission Rule 251.16

Entity Efforts Provide a narrative summarizing the entity's efforts to reprogram the telephone system

Phone System(s)

Please add at least one phone system to the waiver.

Phone System #{{$index + 1}}

Manufacturer Name

Model Number

Estimated Cost to Reprogram

Estimated Cost to Replace

Please confirm that either reprogramming or replacement cost is filled out.

Address(es) Served By Phone System

Address	City	State	Zip
{{a.address}}	{{a.city}}	{{a.state}}	{{a.zip}}

Please add at least one address to phone system.
	Before progressing to next step, confirm the address by clicking the blue check button or discard by clicking the red X.

Add Phone System Serving Address

Add Phone System

Review Forms

	Form Name
Download	{{f.name}}

You are not done yet, please continue to step 6 and submit your waiver request!

Submit

By clicking submit waiver, you assert the following:

Notwithstanding the foregoing good faith efforts to reprogram or replace non-compliant telephone systems, compliance with the rule would, at this time, be unduly and unreasonably cost prohibitive. Accordingly, we request a one-year waiver for the following non-compliant telephone system(s).

I confirm on behalf of the identified entity, that until the telephone systems identified in this affidavit are brought into compliance with Kari’s Law and Commission Rule 251.16 we will (or have) placed stickers with instructions for accessing 9-1-1 service in at least 16-point boldface type in a contrasting color using an easily read font immediately adjacent to, and optionally on, each telephone handset that utilizes the non-compliant telephone system and is written in English and Spanish.

Kari's Law - Request Waiver

Request Waiver

Waiver Information