Fee Waiver Application Form (Grades 7-12)

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FEE WAIVER APPLICATION (GRADES 7-12 )
Please read the School Fees Notice before completing the application!
All information on this application will be kept confidential
SECTION A: STUDENT INFORMATION AND BASIS FOR FEE WAIVER.
Name of student: ____________________________________________Student #:_____________________________
Address: ________________________________________________________________________________________
School: __________________________________________________________________Grade level: ____________
Name of parent or guardian: ______________________________________ Phone number: _____________________
Please check if applicable: (attach supporting documents for each category that applies)
______ Student is eligible based on income verification. (See Section D, Page 2 of 2)
______ Student receives (SSI)* Supplemental Security Income (QUALIFIED CHILD WITH DISABILITIES)
______ Family receives TANF (currently qualified for financial assistance or food stamps)
______ Student is in Foster Care (under Utah or local governmental supervision)
______ Student is in State Custody
*Please note: Students who receive Survivor Benefits Do Not Quality for the SSI category listed above.
Parent(s)/guardian(s) shall provide income eligibility documentation in the form of income tax returns or current pay
stubs demonstrating compliance with requirements consistent with state law and school district policies and/or
guidelines for all of the above qualifiers.
If none of the above apply but you wish to apply for fee waivers or other help with school fees because of serious
financial problems, please state the reason(s) for the request:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
(If you need more space, please continue on the back of this page)
Please check the school fee schedule and list all fees that you wish to have waived. If your student is eligible for fee
waivers, all of those fees identified will be waived. Please note that costs for yearbooks, class rings, letter jackets,
school pictures, and similar items are not fees and will not be waived. Students may be required to pay fees for
concurrent enrollment or advanced placement courses. The portion of the fees related specifically to college or
post-secondary grades or credit is not subject to fee waiver.
Fee Description
Amount
Fee Description
Amount
______________________________
__________
______________________________
__________
______________________________
__________
______________________________
__________
______________________________
__________
______________________________
__________
Please give this application to the Principal, Assistant Principal, or the School Fee Counselor when you have
finished filling it out. All fee payments will be suspended until the school has determined if your student is eligible
for fee waivers. You will then be given a written notice of that decision. The school shall require you to present
proof of eligibility. State law requires schools or school districts to require DOCUMENTATION of fee waiver
eligibility if parent must "apply for fee waivers." State law also requires that school districts provide alternatives in lieu
of fee waivers, “to the fullest extent reasonably possible according to individual circumstances of both fee waiver
applicant and school,” consistent with local board policies and/or guidelines which may include tutorial assistance to
other students, assistance before or after school to teachers and other school personnel on school related matters, and
general community or home service. If your student is eligible for a waiver, the school cannot require you to agree to an
installment payment plan or sign an IOU in place of a waiver.
I HEREBY CERTIFY THAT THE INFORMATION AND DOCUMENTATION I HAVE PROVIDED IS TRUE
AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
I ALSO GIVE SCHOOL
OFFICIALS PERMISSION TO USE THIS FORM AS A RELEASE TO OBTAIN INFORMATION
NECESSARY FOR VERIFICATION OF ELIGIBILITY.
DATE: _______________________
_____________________________________________________________
PARENT'S OR GUARDIAN'S SIGNATURE
USOE 3/23/16
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