Household size (including student): Total annual household income before taxes (all sources):
My signature confirms that:
• I meet the criteria above and am requesting an application fee waiver.
• I agree to provide financial documentation in support of this fee waiver if it is requested of me.
• I understand that if I have received my limit of seven fee waivers during the calendar year, my application may be held
pending receipt of the appropriate fee(s).
Signature of Student: Date:
Signature of Head of Household:
2020 FEE WAIVER REQUEST FORM
THE STATE UNIVERSITY OF NEW YORK
Application Services Center (ASC)
P.O. Box 22007
Albany, New York 12201-2007
Verification (Option 1 or Option 2 required)
Household Size
1
2
3
4
5
6
7
8
$23,107
31,284
39,461
47,638
55,815
63,992
72,169
80,346
*
Annual Income
*Plus $8,177 for each family member in excess of eight
Zip
6K
Internal Use Only
Student Confirmation (all fields are required)
Questions? Call the Recruitment Response Center at 1.800.342.3811, Monday-Friday, between 8:30 a.m. and 4:30 p.m. (EST).
To be considered for an application fee waiver from The State University of
New York, students must:
• Complete and mail the 2020 Fee Waiver Request Form (this form)
with required signatures to the address above. Other acceptable fee
waiver forms include an ACT or SAT fee waiver (not registration card)
or other official form from a recognized community agency such as the
Urban League.
• Be a resident of New York State or a citizen of the United States.
• Meet the financial eligibility criteria shown in the table to the right.
If eligibility is confirmed, the Application Services Center will grant an application
fee waiver for the first seven campus choices selected.
Option 1: Counselor/Advisor Certification
To the best of my knowledge, the student meets the requirements outlined on this fee waiver form. I have confirmed with the student
that this request is applicable for up to seven campus choices and appropriate processing fee(s) for additional campus choices should
be submitted with the application. The student is aware that financial documentation in support of this fee waiver may be requested.
School Counselor/Transfer Advisor Signature: Date:
High School/College:
Option 2: Proof of Income
Students who are unable to obtain a School Counselor or Transfer Advisor signature, must provide proof of income and attach a
copy to this form. Proof of income may include any one of the following:
• Most recent federal tax return (Form 1040) • Statement of Social Services benefits
• Student Aid Report (SAR) from the FAFSA (If income • Proof of unemployment insurance benefits
information was not transferred from IRS.)
Applicant ID Number:
Name: / /
Address:
Phone Number: Date of Birth:
City State
Name
Phone Number
(including area code):
Last First Middle
Street/P.O. Box Apt #
City State/Province Zip/Postal Code Country
6K
