Request To Waive Admission Application Fee - 2012-2013

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CSU Office Use Only
Approved
2012-2013
Request to Waive
Date: _______________
Denied
By _______________________________
Admission Application Fee
Campus to which you are submitting this form:
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 skip
Section D.
Are you a California resident?
Yes
No
• You were born before January 1, 1989.
Are you a U.S. citizen?
Yes
No
• You are currently an active duty member or a veteran of the U.S. Armed Forces.
• You are an orphan or ward of the court or emancipated or in foster care.
If you are not a California resident, you are not eligible for a fee waiver.
• You are married or registered with the California Secretary of State as a domestic
If you are not a U.S. citizen, you must complete the reverse side of this form
partner.
before your eligibility for a fee waiver can be determined.
• You have dependents other than a spouse.
• You will be enrolled in a graduate degree program.
Incomplete responses will delay processing and may be cause for denial of
this request.
If you do not satisfy any of the above conditions, complete Sections D and E.
Section C
Section D
Financial Information from
Applicant’s Parents**
Financial Information from Applicant*
If all answers in Section B are “No,” applicant’s parents must complete this section and
Total size of your household in 2012-2013
____________
sign the Certification in Section E.
(include yourself, your spouse if you are married, your
registered domestic partner and any other legal
Total size of parents’ household in 2012-2013
___________
dependents —including children—who are living with you)
(include applicant, parent's registered domestic partner,
other dependent children, and other dependents)
Number of dependent children living with you
____________
a. Parents’ Adjusted Gross Income (AGI) for 2011
Applicant’s (and, if married, spouse’s) total 2011
$ __________
income from all sources other than financial aid
$____________
b. Parents’ untaxed income and benefits for 2011
$ __________
(include earnings from work and benefits such
Total (a + b)
$
as TANF, veterans benefits, etc.)
____________
** If you are registered with the California Secretary of State as a domestic partner, your household size must include your
* If you are registered with the California Secretary of State as a domestic partner, your household size must include
partner and your combined legal dependents, and the partner's income must be included along with your income. If
your partner and your combined legal dependents, and the partner's income must be included along with your
your custodial parent is registered with the California Secretary of State as a domestic partner, the parent's household
income. If your custodial parent is registered with the California Secretary of State as a domestic partner, the
must include the partner and the combined dependents, and the partner's income must be included along with your
parent's household must include the partner and the combined dependents, and the partner's income must be
parent's income.
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 completed the information in Section D, at least one of your parents must also sign this form.
When you have completed and signed this “Request, ” send it to the Office of Admissions at the campus to which you are applying.
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