□
□
□
□
□ □
UNIVERSITY
of
HAWAI'1•
HILO
□ □
Request for Waiver of
University Application Fee
(Hawaii Residents)
First Name Last Name Middle Name/MI Any other names used
UH ID or SSN
Permanent Address: Street City State Zip
Phone Number: e-mail:
SECTION I: PLEASE WAIVE MY APPLICATION FEE BECAUSE: ( check all that apply)
A.
I
participate in the school lunch program at my sch
ool
B
.
I
receive assistance under the "Aid to Families with Dependent Children" (AFDC) progra
m
C. M
y family receives assistance from DSSH (food stamps, house allowance etc. ( and I am claimed as a dependent on my
p
arent's/legal guardian's personal income ta
x
D. I
receive assistance from DSS
H
S
ECTION II: STUDENT'S CERTIFICATION
I certify that the information provided is complete and true to the best of my knowledge and belief. I understand that providing incomplete,
incorrect or false information my result in the recision of my admission. I understand that I may be required to produce certified documents
to substantiate my claim for a waiver of the application fee.
Student's Signature Date
SECTION III: VERIFICATION (to be completed by appropriate authority- High School counselor, DSSH officer etc.)
I certify that to the best of my knowledge, the student above is eligible for a waiver of the application fee based on the items listed in
Section I (A-C) or provide a copy of DSSH statement.
A. B. C. DSSH statement provided
Print Name of Counselor, Principal or other department official Name of Institution/ Agency/ Department
Phone Number: Fax Number: e-mail:
Official's Signature
Date
INSTRUCTIONS FOR STUDENTS
To be eligible for a waiver of the application fee, you must be a permanent resident of the State of Hawaii. You must meet one of the eligibility requirements
noted above (A-D). Your request must be verifiable.
University of Hawaii at Hilo: 200 West Kawili St., Hilo, HI 96720 Phone: (808) 932-7446 or (800) 897-4456 Fax: (808) 932-7459 email:uhhadm@hawaii.edu
click to sign
signature
click to edit
![]()
