Fillable INSTRUCTIONS Application Fee Waiver Form (Arizona)

Fill Online, Printable, Fillable, Blank INSTRUCTIONS Application Fee Waiver Form (Arizona) Form

Use Fill to complete blank online ARIZONA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

INSTRUCTIONS Application Fee Waiver Form (Arizona)

On average this form takes 16 minutes to complete

The INSTRUCTIONS Application Fee Waiver Form (Arizona) form is 4 pages long and contains:

  • 2 signatures
  • 16 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

BROWSE ARIZONA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Application Fee Waiver Form
INSTRUCTIONS
Application Fee Waiver Form: A.R.S. § 41-1080.01 provides a waiver of initial application fees for qualified
applicants.
To qualify, an applicant’s income shall not exceed 200% of the federal poverty guidelines. If you believe that
you qualify for the waiver, complete the application fee waiver form along with your liense application and
provide the required documents.
Waiver Requirements
1. The applicant must complete and submit:
• The application fee waiver form signed by the applicant and spouse, if applicable.
• Provide required financial document(s).
Special Instructions
• The applicant must complete all applicable fields on the application fee waiver form. Incomplete application
fee waiver forms will be denied.
• The application fee waiver form, completed application with all supportive documents, and financial
document(s) have to be submitted together. Failure to submit all documents at the same time will
result in the waiver being denied.
• If married and not legally separated, the application fee waiver form must be signed by the applicant and
spouse. Application fee waiver forms not signed by both parties will be denied.
• All fees are non-refundable.
Financial Documents
To determine eligibility, the applicant seeking the waiver, must provide the financial document(s) consistent with
your status, as listed below.
1. Has income and regularly files federal tax return
• Single – must provide copy of most recent federal tax return.
• Married Filing Joint – must provide copy of most recent federal tax return.
• Married Filing Separate – must provide copies of applicant’s and spouse’s most recent federal tax return.
• Married Filing Separate and legally separated - must provide copies of applicant’s most recent federal
tax return and a copy of the court order demonstrating legal separation.
2. Has income but does not regularly file federal tax return
• Single – must provide copies of most recent W2 and/or 1099.
• Married - must provide copies of applicant and spouse most recent W2 and/or 1099.
• Married and legally separated - must provide copies of applicant most recent W2 and/or 1099 and a copy
of the court order demonstrating legal separation.
3. Has no income and does not regularly file federal tax return
• Single – provide application fee waiver form.
• Married - provide application fee waiver form.
• Married and legally separated - provide application fee waiver form and a copy of court order
demonstrating legal separation.
2
Marital Status
Arizona State Board of Pharmacy
1616 W. Adams, Suite 120, Phoenix, AZ 85007
PH: 602-771-2727
Single
Married
Legally Separated
Divorced
Widowed
Filing Status
Single
Married Filing Jointly
Married Filing Separately
Head of Household
Document(s) Submitted With Waiver Form
Applicant’s Federal Tax Return
Applicant’s W2
Applicant’s 1099
Spouse’s Federal Tax Return
Spouse’s W2
Spouse’s 1099
Total Annual Gross Income: Year of Total Annual Gross Income: Family Size:
Spouse Legal Name (Last, first, middle initial)
Spouse Social Security #
Street Address
City, State, ZIP Code
Primary Phone Number | Other Phone Number
Email Address
Application Fee Waiver Form
APPLICANT INFORMATION
ALL FIELDS ARE REQUIRED
Date
Legal Name (Last, first, middle initial)
Social Security #
Other Legal Name (Last, first, middle initial) (Maiden)
Street Address
City, State, ZIP Code
Primary Phone Number | Other Phone Number
Email Address
3
EMPLOYMENT HISTORY OF MOST RECENT 2 EMPLOYERS (APPLICANT)
Employer Name
Supervisor’s Name
Working Title
Supervisor’s Telephone #
Street Address
City, State, ZIP Code
Dates of Employment
Annual Salary
Employer Name
Supervisor’s Name
Working Title
Supervisor’s Telephone #
Street Address
City, State, ZIP Code
Dates of Employment Annual Salary
EMPLOYMENT HISTORY OF MOST RECENT 2 EMPLOYERS (SPOUSE – IF APPLICABLE)
Employer Name
Supervisor’s Name
Working Title
Supervisor’s Telephone #
Street Address
City, State, ZIP Code
Dates of Employment
Annual Salary
Employer Name
Supervisor’s Name
Working Title
Supervisor’s Telephone #
Street Address
City, State, ZIP Code
Dates of Employment
Annual Salary
4
VERIFICATION BY OATH OR AFFIRMATION OR DECLARATION
The undersigned declares under penalty of perjury under the laws of Arizona, that he/she:
• Is the person referred to in the foregoing application;
• That the statements are true in every respect to the best of his/her knowledge;
• That he/she has not suppressed any information that would affect this application;
• That he/she has read and understands that failure to disclose the requested information or disclosure of false
information or disclosure of misleading information may constitute fraud and may result in denial of
licensure/certification or disciplinary action, up to and including revocation, taken against an issued license or
certificate;
Applicant's Signature
Date
Spouse's Signature
Date
For Administrative Use Only:
Approved / Denied
Date Reviewed / Initials
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

INSTRUCTIONS Application Fee Waiver Form (Arizona)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document