Request To Waive Admission Application Fee - 2012-2013 printable pdf download

CSU Office Use Only

Approved

2012-2013

Request to Waive

Date: _______________

Denied

By _______________________________

Admission Application Fee

Campus to which you are submitting this form:

Social Security Number

Please Print:

Applicant's Name__________________________________________________________________

(Last)

(First)

(Middle)

Phone Number ( ____ ) ___________________

Address _________________________________________________________________________

E-mail:

City ____________________________________________ State_______ Zip Code ____________

___________________________________

The $55 admission application fee may be waived if you meet the eligibility standards based on the information provided on this form.

Section A

Section B

To All Applicants

To Be Completed by All Applicants

If you satisfy one of the following conditions, complete Sections C and E and skip

Section D.

Are you a California resident?

Yes

• You were born before January 1, 1989.

Are you a U.S. citizen?

Yes

• You are currently an active duty member or a veteran of the U.S. Armed Forces.

• You are an orphan or ward of the court or emancipated or in foster care.

If you are not a California resident, you are not eligible for a fee waiver.

• You are married or registered with the California Secretary of State as a domestic

If you are not a U.S. citizen, you must complete the reverse side of this form

partner.

before your eligibility for a fee waiver can be determined.

• You have dependents other than a spouse.

• You will be enrolled in a graduate degree program.

Incomplete responses will delay processing and may be cause for denial of

this request.

If you do not satisfy any of the above conditions, complete Sections D and E.

Section C

Section D

Financial Information from

Applicant’s Parents**

Financial Information from Applicant*

If all answers in Section B are “No,” applicant’s parents must complete this section and

Total size of your household in 2012-2013

____________

sign the Certification in Section E.

(include yourself, your spouse if you are married, your

registered domestic partner and any other legal

Total size of parents’ household in 2012-2013

___________

dependents —including children—who are living with you)

(include applicant, parent's registered domestic partner,

other dependent children, and other dependents)

Number of dependent children living with you

____________

a. Parents’ Adjusted Gross Income (AGI) for 2011

Applicant’s (and, if married, spouse’s) total 2011

$ __________

income from all sources other than financial aid

$____________

b. Parents’ untaxed income and benefits for 2011

$ __________

(include earnings from work and benefits such

Total (a + b)

as TANF, veterans benefits, etc.)

____________

** If you are registered with the California Secretary of State as a domestic partner, your household size must include your

* If you are registered with the California Secretary of State as a domestic partner, your household size must include

partner and your combined legal dependents, and the partner's income must be included along with your income. If

your partner and your combined legal dependents, and the partner's income must be included along with your

your custodial parent is registered with the California Secretary of State as a domestic partner, the parent's household

income. If your custodial parent is registered with the California Secretary of State as a domestic partner, the

must include the partner and the combined dependents, and the partner's income must be included along with your

parent's household must include the partner and the combined dependents, and the partner's income must be

parent's income.

included along with your parent's income.

Additional information in support of my request for waiver of the $55 application fee: ____________________________________________________________________

_____________________________________________________________________________________________________

Section E

Certification

I (we) certify under penalty of perjury under the laws of the State of California that all information reported on this form is true, complete, and accurate.

Applicant’s Signature

_____________________________________________________________________________

Date

Father’s Signature

Mother’s Signature

________________________________________________________________________________

____________________________________________________________________________

Date

Father’s Name (please print)

Mother’s Name (please print)

________________________________________________________

______________________________________________________________________