Office of Court Management
Two Center Plaza, Room 540
Boston, MA 02108
Email: exams@jud.state.ma.us
Telephone: (617)742-8575
https://www.mass.gov/jobs-with-the-court-system
MASSACHUSETTS TRIAL COURT
Request for Waiver of the Examination Fee
Exam Title:_______________________________________________________________________________
Registrant Name:__________________________________________________________________________
Home Address:____________________________________________________________________________
Email Address:__________________________________Daytime Telephone Number:__________________
Please note: This form and the required supporting documentation must be either e-mailed to
exams@jud.state.ma.us or faxed to (617)742-0968 on or before April 22, 2019.
I request a waiver of the Examination Processing Fee and attest that I am an approved participant in the
following program(s) ( please indicate at least one):
___Free and reduced price lunch or milk at school ___ Supplemental Nutritional Assistance
or day care center Program (SNAP- formerly Food Stamps)
___ Fuel Assistance ___ Temporary Assistance for Needy Families (TANF)
___ Massachusetts Refugee Resettlement Program ___ Transitional Aid to Families and Dependent
___Municipal Veterans Benefits under MGL Ch. 115 Children (TAFDC)
___ Rental Assistance ___ Unemployment Insurance (UI)
___ Social Security ___ Veterans Administration Vocational Rehabilitation
___ Supplemental Security Income (SSI)
___ Vocational Rehabilitation Services (VR)
___ Women Infants Children Program (WIC)
I am submitting the required supporting documentation, which must be in the following form:
1. Official receipts, check stubs, or agency verification documents (ID cards or member cards are not
acceptable documentation);
2. Which are dated within the past 12 months:
3. Are addressed to me:
4. And verify that I have received the assistance indicated above within the past 12 months.
I understand that it is my responsibility to ensure that this Form and the required supporting documentation are
provided as outlined above. I understand that if I do not submit acceptable supporting documentation, my
fee waiver request will be denied. I understand that in order to take an examination, I must either be approved
for a fee waiver or if my fee waiver request is denied, I register and pay the required fee.
I hereby declare under the penalties of perjury that the statement above is true. I authorize the agency
administering the benefits I have indicated above to release information sufficient to verify my claim should a
question of authenticity arise in regards to my fee waiver request.
____________________________________________ ________________________________
Registrant’s Signature Date of Request
Revised 1/2019
Court Officer Entrance Exam 2019
