APPLICATION FEE WAIVER: A waiver of application fee will be allowed if you are unemployed and
primarily responsible for the support of a household. In addition, a waiver of application fee will be
allowed if you are determined eligible for Medicaid, or receiving Supplemental Security Income
payments, or Public Assistance (Temporary Assistance for Needy Families/Family Assistance or
Safety Net Assistance) or are certified Job Training Partnership Act/Workforce Investment Act eligible
through a State or local social service agency. All claims for application fee waiver are subject to
verification. If you can verify eligibility for application fee waiver, complete a “Request for
Application Fee Waiver and Certification” form and submit it with your application by the
close of business on the Application Deadline as listed on the Examination Announcement.
Application Fee Waiver Request and Certification Form
Civil Service Law Section 50.5(b): “…fees shall be waived for candidates who certify to the state civil
service department, a municipal commission or regional commission that they are unemployed and
primarily responsible for the support of a household, or are receiving public assistance.”
I request that my application fee(s) for the examination(s) listed below be waived in accordance
with Section 50.5(b) of the State Civil Service Law.
Examination Title(s) Exam No(s). Examination Test Date
Check the box(es) below that apply to you:
I am currently unemployed and I am primarily responsible for support of a household
NOTE: Individuals who can be claimed as a dependent on any other person’s tax return ARE NOT eligible
for application fee waiver as head of household.
I am currently:
Eligible for Medicaid
Receiving Supplemental Security Income (SSI) payments
Receiving Public Assistance (Temporary Assistance for Needy Families/Family Assistance or Safety Net
Assistance):
Enter Public Assistance Case Number
Certified Job Training Partnership Act/Workforce Investment Act eligible through a State or local social
service agency
**************************************
Affirmation
*****************************************
I have read the above portion of Section 50.5(b) of the Civil Service Law relating to the waiver of
application fees and certify that I am qualified to receive such waiver for the reasons indicated above. I
understand that my claim for application fee waiver may be investigated and I may be disqualified from
the listed civil service examination(s) if I make any false statement regarding my eligibility for application
fee waiver.
____________________________________ -- --
Candidate’s First and Last Name (Please Print) Candidate’s Social Security Number
__________________________________ ____________________________
Candidate’s Signature Date
