Exam Application Fee Waiver Request and Certification Form
Civil Service Law Section 50.5 (b): “…fees shall be waived for candidates who certify to the (Fulton County
Personnel Department) 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.
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.
Verification: You must provide us with the following information before the exam fee will be waived:
• We’ll need to see your
Statement of Benefits Paid
• List all names, ages, relationships to you and the monthly income of anyone residing with you. If extra
space is needed, please attach an additional page.
❑ 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
Verification: You must provide us with the following information before the exam fee will be waived:
• Verification from the Department of Social Services stating that you are currently eligible for the
services indicated by the box checked above.
YOUR NEW YORK STATE BENEFIT CARD WILL NOT BE ACCEPTED AS PROOF OF ELIGIBILITY
**************************** 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 Last 4 Digits of Social Security Number
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signature
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