variance request for child placing agency/child caring institution/court operated facility rules
Michigan Department of Health and Human Services
Division of Child Welfare Licensing
Date of Request	CPA/CCI Name	License Number
Chief Administrator
Address
City	State	Zip Code
Specify licensing rule(s) that the variance is being requested for.
Provide reason/rationale for the variance request.
If the variance is being requested for a specific employee or proposed employee’s qualifications, include the employee and position.
Describe the circumstances surrounding the non-compliance and the reason that the compliance cannot be met.
Describe proposed alternative to the requirement of the rule.
Describe specific steps that will be taken to achieve rule compliance.
Describe length of time that is needed until compliance can be met.
Attach supporting documents to the request, if applicable.
Name of Chief Administrator	Signature of Chief Administrator	Date
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.