111—12.11 (17A) Appeals; judicial review. Judicial review of the director’s decision to grant or deny a waiver petition may be taken in accordance with Iowa Code chapter 17A.
Exhibit A
Sample Petition (Request) for Waiver

BEFORE THE DEPARTMENT FOR THE BLIND	
Petition by (insert name of petitioner)
for the waiver of (insert rule citation)
relating to (insert the subject matter).	}	PETITION FOR
WAIVER	
Requests for waiver from a department rule shall include the following information in the petition for waiver where applicable and known:
	  a.   	 Provide petitioner’s (person asking for a waiver) name, address, and telephone number.
	  b.   	 Describe and cite to the specific rule from which a waiver is requested.
	  c.   	 Describe the specific waiver requested and include the exact scope and time period that the waiver will extend.
	  d.   	 Explain the important facts that the petitioner believes justify a waiver. Include in your answer why (1) applying the rule will result in hardship/injustice to the petitioner; (2) granting a waiver or variance to the petitioner is consistent with the public interest; and (3) granting the waiver or variance will not prejudice the substantial legal rights of any person.
	  e.   	 Provide a history of prior contacts between the department and petitioner relating to the regulated activity, license, or grant that would be affected by the waiver. Include a description of each affected license or grant held by the petitioner, any notices of violation, contested case hearings, or investigative reports relating to the regulated activity, license, or grant within the last five years.
	  f.   	 Provide a detailed statement of the impact on any person affected by the granting of a waiver.
	  g.   	 Provide information known to the petitioner regarding the department’s treatment of similar cases.
	  h.   	 Provide the name, address, and telephone number of any state or federal public agency or political subdivision which also regulates the activity in question or which might be affected by the granting of a waiver.
	  i.   	 Provide the name, address, and telephone number of any person or entity that would be adversely affected or disadvantaged by the granting of the waiver.
	  j.   	 Provide the name, address, and telephone number of any person with knowledge of the relevant or important facts relating to the requested waiver.
	  k.   	 Provide signed releases of information authorizing persons with knowledge regarding the request to furnish the department with information relevant to the waiver.
I hereby attest to the accuracy and truthfulness of the above information.

 	Petitioner’s Signature	 	Date	
Petitioner should note the following when requesting or petitioning for a waiver:
	  1. 	 The petitioner has the burden of proving to the director that (a) application of the rule to the petitioner would result in hardship or injustice to the petitioner; (b) waiver on the basis of the particular circumstances relative to the petitioner would be consistent with the public interest; (c) waiver in the specific case would not prejudice the substantial legal rights of any person; and (d) waiver in the specific case would not have a negative impact on any person affected by the waiver.
	  2. 	 The director may request additional information from or request an informal meeting with the petitioner prior to issuing a ruling granting or denying a request for waiver.
	  3. 	 All petitions for waiver must be submitted in writing to the Director, Department for the Blind, 524 Fourth Street, Des Moines, Iowa 50309-2364. If the petition relates to a pending contested case, a copy of the petition shall also be filed in the contested case proceeding.