TO: DEAN/DIRECTOR OF ADMISSION AT
NAME OF COLLEGE OR UNIVERSITY
Request for Admission
Application Fee Waiver
CERTIFICATION STATEMENT: I certify that I understand and meet all eligibility requirements to request an admission application fee waiver.
STUDENT’S NAME STUDENT’S SIGNATURE
STUDENT’S ADDRESS
CITY
STATE ZIP
CERTIFICATION STATEMENT: I certify that the student named on this form is either (a) currently enrolled in the 11th or 12th grade at this school,
or if not currently enrolled, (b) an individual who is seeking enrollment as an undergraduate to an institution of postsecondary education; AND meet at
least one
of the indicators of economic need checked below.
AUTHORIZED OFFICIAL'S NAME AUTHORIZED OFFICIAL'S SIGNATURE
AUTHORIZED OFFICIAL'S TITLE AUTHORIZED OFFICIAL'S EMAIL
NAME OF SECONDARY EDUCATIONAL INSTITUTION OR ORGANIZATION CEEB# OR PROGRAM#
ADDRESS
PHONE
**SEND THIS FORM DIRECTLY TO THE POSTSECONDARY
INSTITUTION/ORGANIZATION**
*To view USDA Income Eligibility Guidelines for the Free or Reduced Price Lunch Program, click on the Frequently Asked Questions by vising http://bit.ly/NACACfeewaiver.
Rev. 2021
ECONOMIC NEED: The student must meet at
of the following indicators of economic need. If no item is checked, the request will be
denied.
AUTHORIZED OFFICIAL: Print or type the information requested below and check at
of the indicators of economic need. You must
personally sign the Certification Statement.
STUDENT: Print or type the information requested below. You must personally sign the Certification Statement.
Student has received or is eligible to receive an ACT or SAT testing fee waiver.
Student is enrolled in or eligible to participate in the Federal Free or Reduced Price Lunch program (FRPL).
Student’s annual family income falls within the income Eligibility Guidelines* set by the USDA Food and Nutrition Service.
Student is enrolled in a federal, state or local program that aids students from low-income families (e.g., GEAR UP, TRIO such as Upward
Bound or others).
Student’s family receives public assistance (e.g., SSI, SNAP, or others).
Student lives in federally subsidized public housing, a foster home, or is homeless.
Student is a ward of the state or an orphan.
Student has applied to FAFSA and is eligible to receive Pell Grant (provide a copy of the most recent Student Aid Report – SAR).
Other request from high school principal, high school counselor, financial aid officer, community advisor/leader or other official who can
attest to the student’s circumstances.
Given my knowledge of this student’s family circumstances and after reviewing the eligibility guidelines, I believe that providing the
application fee would present a hardship. Use the space below to explain or add supplemental information to the items above:
_______________________________________________________________________________________________________
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