Fee Waiver Request Form - Monroe County Dept. Of Public Health printable pdf download

Fee Waiver Request Form - Monroe County Dept. Of Public Health

FEE WAIVER REQUEST FORM

Date____________

I hereby request a waiver of ____ (50%) _____ (100%) of the Environmental Health Fee in the amount of $_______ for

environmental services received. I request this Waiver in view of the fact that our organization is:

_____ Charitable non-profit

_____

Governmental receiving more than 50% of operating funds from general tax revenues

FOR A CHARITABLE NON-PROFIT YOU MUST ATTACH THE FOLLOWING:

___ A copy of your INTERNAL REVENUE EXEMPTION DOCUMENT 501 (C) 2 OR 3

For those entities requesting 100% waiver of Environmental Health Fees, you must also provide

documentation that your organization’s annual expenses are $50,000 or less. In these cases,

please also include:

Please return forms to:

___

A copy of a completed Internal Revenue Service Form 990, 990-EZ, 990-PF, 990-N

Monroe County Dept. of

Public Health

111 Westfall Rd. Room 1020

Rochester, NY 14620

___ A copy of your organization’s annual financial statement.

(Please print)

Services rendered: ___________________________________________________________

Location: ___________________________________________________________________

Fee required: _________

Organization Name: ____________________________________________

Mailing Address: _______________________________________Phone #_______________________________

Signature & Title: ______________________________________________________________________

Print Name: ________________________________________________________

DO NOT WRITE BELOW THIS LINE

FOR OFFICE USE ONLY:

Recommend _____________

DATE: ____________________________________

Deny ___________________

This Department has found your request for Waiver to be in order and hereby issues a Waiver for ___50% ___100% of the

payment of this and future Environmental fees under the condition that your organization is and remains:

_____

Charitable non-profit

_____

Governmental receiving more than 50% of operating funds from general tax

revenues.

Operating with annual expenses of $50,000 or less – proof provided.

_____

Sincerely,

Michael D. Mendoza, MD, MPH, MS

Interim Commissioner of Public Health

Rev 4/2016

Fee Waiver Request Form - Monroe County Dept. Of Public Health

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