2014-2015 Request To Waive Undergraduate Admission Application Fee Form
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2CSU Office Use Only
Approved
2014-2015
Request to Waive
Denied
Date:
_______________
Undergraduate
Admission Application Fee
By
_______________________________
CSU campus to which you are submitting this form:
(Please DO NOT send this form to the Chancellor's Office.)
Social Security Number
Please Print:
Applicant's Name
__________________________________________________________________
(Last)
(First)
(Middle)
Phone Number
( ____ ) ___________________
Address
_________________________________________________________________________
E-mail:
City
State______ Zip Code
____________________________________________
____________
___________________________________
The $55 admission application fee may be waived if you meet the eligibility standards based on the information provided on this form.
Section A
Section B
To All Applicants
To Be Completed by All Applicants
If you satisfy one of the following conditions, complete Sections C and E and
Are you a California resident?
Yes
No
skip Section D.
Are you a U.S. citizen?
Yes
No
• You were born before January 1, 1991.
• You are currently an active duty member or a veteran of the U.S. Armed Forces.
If you are not a California resident, you are not eligible for a fee
• You are an orphan or ward of the court or emancipated or in foster care.
waiver, unless you meet the criteria in Section II on the reverse side
• You are married or registered with the California Secretary of State as a
of this form.
domestic partner.
If you are not a U.S. citizen, you must complete Sections I and II on
• You have dependents other than a spouse.
the reverse side of this form.
Incomplete responses will delay processing and may be cause for
If you do not satisfy any of the above conditions, complete Sections D and E.
denial of this request.
Section C
Section D
Financial Information from
Financial Information from Applicant*
Applicant’s Parents**
Total size of your household in 2014-2015
____________
If all answers in Section B are “No,” applicant’s parents must complete this
(include yourself, your spouse if you are married, your
section and sign the Certification in Section E.
registered domestic partner and any other legal
dependents —including children—who are living with you)
Total size of parents’ household in 2014-2015
__________
(include applicant, parent's registered domestic partner,
Number of dependent children living with you
____________
other dependent children, and other dependents)
Applicant’s (and, if married, spouse’s) total 2013
a. Parents’ Adjusted Gross Income (AGI) for 2013
$ __________
income from all sources other than financial aid
$
___________
b. Parents’ untaxed income and benefits for 2013
$ __________
(include earnings from work and benefits such
as TANF, veterans benefits, etc.)
Total (a + b)
$ __________
* If you are registered with the California Secretary of State as a domestic partner, your household size
** If you are registered with the California Secretary of State as a domestic partner, your household size
must include your partner and your combined legal dependents, and the partner's income must be
must include your partner and your combined legal dependents, and the partner's income must be
included along with your income. If your custodial parent is registered with the California Secretary
included along with your income. If your custodial parent is registered with the California Secretary
of State as a domestic partner, the parent's household must include the partner and the combined
of State as a domestic partner, the parent's household must include the partner and the combined
dependents, and the partner's income must be included along with your parent's income.
dependents, and the partner's income must be included along with your parent's income.
Additional information in support of my request for waiver of the $55 application fee: ____________________________________________________________
_____________________________________________________________________________________________________
Section E
Certification
I (we) certify under penalty of perjury under the laws of the State of California that all information reported on this form is true, complete, and accurate.
Applicant’s Signature
____________________________________________________________________
Date
Father’s Signature
Mother’s Signature
___________________________________________________________________________
_______________________________________________________________________
Date
Date
Father’s Name (please print)
Mother’s Name (please print)
_________________________________________________
______________________________________________________________
If you have completed the information in Section D, at least one of your parents must also sign this form.
When you have completed and signed this “Fee Waiver Request Form,” send it to the Office of Admission at the CSU campus to which you are applying for admission.
sas/aa/csu
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