Fillable FALL 2021 APPLICATION FEE WAIVER APPEAL INFORMATION

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FALL 2021 APPLICATION FEE WAIVER APPEAL INFORMATION

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FALL 2021 APPLICATION FEE WAIVER APPEAL INFORMATION
In case of financial hardship, the California State University Office of the Chancellor has allowed each CSU campus a
limited number of undergraduate application fee waivers for residents of California. Only California residents are eligible
for application fee waivers. Students without lawful immigration status, who qualify for an AB540 non-resident tuition
exception, may also apply for a fee waiver.
The attached Application Fee Waiver Appeal form, including this cover sheet, must be completed and submitted before
the Cal State Apply application is submitted - we are unable to issue refunds for submitted application fees! Please allow
at least one week for processing completed Application Fee Waiver Appeal forms and supporting documents.
To apply, please complete this cover sheet and the attached Application Fee Waiver Appeal form. Completed forms and
supporting documents may be submitted to Admissions & Outreach via one of the following:
By Mail
Sacramento State
Office of Admissions & Outreach
6000 J Street, MS 6048
Sacramento, CA 95819
Drop Off
Sacramento State
Admissions & Outreach
Lassen Hall, Room #1102
Monday – Friday 8am – 5pm
By Email
appealadmission@csus.edu
Subject: Fall 2021 App Fee Waiver Appeal
Please do not submit appeal forms without supporting documents attached.
If your Application Fee Waiver Appeal is approved, you will be contacted with instructions on how to submit your Cal State
Apply Application prior to the application deadline.
The deadline to submit an Application Fee Waiver Appeal is December 14, 2020.
SACRAMENTO STATE STUDENT CONTACT INFORMATION
Student Full Name Date
Student Email Phone ( )
Alt. Email Alt. Phone ( )
INTERNAL USE ONLY
Emplid
Appeal Decision Approved Denied Reviewed By Date
Comments
1 of 3
Dec 2020
APPLICATION FEE WAIVER APPEAL
SIGNIFICANT CHANGE IN FINANCIAL CIRCUMSTANCES
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CERTIFICATION
REASON FOR CHANGE:
(Check all appropriate boxes)
Person(s) impacted by change (check all that apply): Student Spouse Parent(s)
Loss/reduction of income Loss/reduction of Benefits (please specify)
Separation/Divorce Death of Parent/Spouse Other (please specify)
Dates change(s) occurred
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If you are eligible for one of the following application fee waivers, please check the box below and attach the appropriate documentation.
Alan Pattee California Veteran Dependents Dependent of Victims of September 11, 2001
I certify that the information provided on this form and attached statement is true, complete, and accurate.
Student Name
Student Signature Date
Parent/Guardian Name
Parent/Guardian Signature Date
CONTINUED ON NEXT PAGE
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10336
* A year’s equivalence at a California community college is either a minimum of 24 semester units of credit or 36 quarter units. Only two (2) years of full time attendance
in credit courses at the California community colleges will count towards the three (3) or more years of attendance. Full-time attendance at a California adult school is a
minimum of 420 hours of attendance for each school year.
II.California Residency Exemption
Select all items that apply to you from each column:
Column A
I have 3 years of attendance at a California high school.
I have 3 or more years of high school coursework and 3 years
of attendance in California elementary schools, California
secondary schools, or a combination of California elementary
and secondary schools.
I attended or attained credits at a combination of California high
school, California adult school, and California Community College for
the equivalent of (3) years or more.
*
Column B
I have graduated or will graduate (before the first term of enrollment
at the CSU) with a California high school diploma or the equivalent
(i.e., California-issued GED, CHSPE).
I completed or will complete (before the first term of enrollment at
the CSU) an associate’s degree from a California Community College
I completed or will complete (before the first term of enrollment at the
CSU) the minimum requirements at a California Community College for
transfer to the California State University.
Dec 2020
Certification of United States Citizenship or Immigration Status
Last Name First Name MI Campus
I.If you are not a U.S. citizen, please check one of the following:
I am a U.S. permanent resident and have a Permanent Resident Card (I-551).
I am a conditional permanent resident (I-151C).
I am a non-citizen with an Arrival-Departure Record (I-94 or I-94A) from the United States Citizenship and Immigration Services (USCIS) showing one
of the following designations: (a)“Refugee,” (b) “Asylum Granted,” (c) “Parolee,” or (d) “Cuban-Haitian Entrant.”
I hold a valid non-immigrant visa. Please state which visa you hold and its expiration date:
Visa
Expiration Date
I am a citizen of the Freely Associated States (Federated States of Micronesia, the Marshall Islands, or Palau).
I am a dependent of a non-citizen classified as NATO-1 through NATO-7.
I am a non-citizen who has been paroled into the U.S. under Section 212(d)(5) of the Immigration and Nationality Act.
I am a victim (or the dependent of a victim) of human trafficking with a Certification or Eligibility Letter to that effect.
I am a non-citizen who has been battered or subjected to extreme cruelty in the United States by my spouse or my parent(s) or a member of my
spouse or parent’s family residing in the same household as me, and I have been approved or have a petition pending which sets forth a prima facie
case of eligibility for an immigrant visa under certain provisions of the Immigration and Nationality Act.
None of the above.
CERTIFICATION – To be read and signed by all individuals completing this form.
I certify under penalty of perjury under the laws of the state of California that the information provided by me on this form is true, complete, and accurate.
Signature Date
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FALL 2021 APPLICATION FEE WAIVER APPEAL INFORMATION

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Completed 15 December 2020

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