Fillable Fee Waiver Application 20-21

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Fee Waiver Application 20-21

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FEE WAIVER APPLICATION (Grades 7-12)
• Please read the School Fees Notice (Grades 7-12) before completing this Application!
• If a school receives verication that a student is eligible for fee waiver, all fees must be waived for that
student.
• All information on this application will be kept condential.
STUDENT INFORMATION:
Name of student: Student #:
Address:
School: Grade level:
Name of parent or guardian
: Phone number:
BASIS FOR FEE WAIVER:
Please check the eligibility that applies: (only 1 is needed)* Verication to submit:
1. Family receives TANF/FEP (Temporary Assistance
• benet verication from the Utah Department of
for Needy Families or Family Employment Program)
Workforce Services for the period for which the fee
(nancial assistance or food stamps)
waiver is sought which may be in the form of an
electronic screenshot of eligibility determination or
status.
2. Student receives Supplemental Security Income (SSI,
• benet verication documents from the Social
QUALIFIED CHILD WITH DISABILITIES)
Security Administration.
3. Student is in Foster Care (under Utah or local
governmental supervision)
• the youth in care required intake form and school
enrollment letter, provided by a case worker from
the Utah Division of Child and Family Services or
the Utah Juvenile Justice Department.
4. Student is in State Custody
5. Student is eligible based on family/household income
verication
• family income verication in the form of income
statements, pay stubs, or tax returns. (See page 2.)
*Please note: The school will require you to provide verication of eligibility. Please attach your verication
documentation to this form when you give this application to your school.
If none of the above apply but you wish to apply for fee waivers because of other extenuating
circumstances, please state the reason(s) for the request:
(Please attach an additional page if needed.)
Please give this application to the Principal/School Director or School Fee Administrator when it is complete.
All fee payments will be suspended until the school has decided if your student is eligible for fee waivers.
You will then be given notice of the decision. If your student is eligible for a waiver, the school cannot require
you to complete service, agree to an installment payment plan, or sign an IOU in place of a waiver.
I HEREBY CERTIFY THAT THE INFORMATION AND ATTACHED DOCUMENTATION I HAVE PROVIDED IS TRUE
AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
DATE: PARENT’S OR GUARDIAN’S SIGNATURE:
Page 1
https://schools.utah.gov/schoolfees
Created by USBE School Fees Team
ADA Compliance 5/1/2020
Revised 3/25/2020
Complete this page ONLY if option#5 was selected under the Basis for Fee Waiver section.
INCOME VERIFICATION FOR ALL HOUSEHOLD MEMBERS: (Required for students who do not qualify based on a special category.)
Household income is determined by adding all household income from all sources and then comparing it to the number of people in the household. A
household is a group of related or unrelated individuals who are not residents of an institution or boarding house but who are living as one economic unit.
This means they generally reside in the same house and share expenses such as rent, utilities and food.
List all income before deductions in the appropriate column(s).
$$$$4
$$$$3
$$$$2
$$$$1
Last First Middle Initial
Name: Earnings from Work
(before deductions)
Monthly Income
Pension/Retirement
Social Security
Monthly Income
Welfare, Alimony, Child
Support, Other Income
Monthly Income
Total Per Person
Total Monthly Income
EXAMPLES OF INCOME:
Earnings from Work Pension/Retirement, Social Security
Welfare, Alimony, Child
Support
Other Income
Wages, salaries and tips, Pensions, supplement, security *TANF payments*, welfare Disability benets; cash withdrawn from
strike benets, income, retirement payments, payments, savings; interest & dividends; income
unemployment comp., Social Security Income (including alimony, and child support from estates, trusts, and investments,
workers’ comp, net SSI a child receives) payments regular contributions from persons not
income from self-owned living in the household; net royalties and
business or farm annuities; net rental income; any other
income
*Receipt of TANF assistance automatically qualies one for fee waiver eligibility. No further proof of income is
needed. Please review Basis for Fee Waiver section and submit application under TANF eligibility.*
INCOME ELIGIBILITY GUIDELINES
For School Year:
July 1, 2020 - June 30, 2021
Household Size Yearly Monthly Twice Per Month Every Two Weeks Weekly
1 16,588 1,383 692 638 319
2 22,412 1,868 934 862 431
3 28,236 2,353 1,177 1,086 543
4 34,060 2,839 1,420 1,310 655
5 39,884 3,324 1,662 1,534 767
6 45,708 3,809 1,905 1,758 879
7 51,532 4,295 2,148 1,982 991
8 57,356 4,780 2,390 2,206 1,103
For each additional
family member, add:
5,824 486 243 224 112
Page 2 Created by USBE School Fees Team
https://schools.utah.gov/schoolfees Revised 3/25/2020
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Fee Waiver Application 20-21

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Completed 6 August 2020

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