Fillable Printable ACT Fee Waiver Form - New York
Fillable Printable ACT Fee Waiver Form - New York
ACT Fee Waiver Form - New York
Household size (including student): Total annual household income before taxes (all sources):
My signature confirms that:
• I meet the criteria above and am requesting an application fee waiver.
• I agree to provide financial documentation in support of this fee waiver if it is requested of me.
• I understand that if I have received my limit of four fee waivers during the calendar year, my application may be held pending
receipt of the appropriate fee(s).
Signature of Student: Date:
Signature of Head of Household:
2016 FEE WAIVER REQUEST FORM
T
HE STATE UNIVERSITY OF NEW YORK
A
pplication Services Center (ASC)
P.O. Box 22007
Albany, New York 12201-2007
Verification (Option 1 or Option 2 required)
Household Size
1
2
3
4
5
6
7
8
$21,775
29,471
37,167
44,863
52,559
60,255
67,951
75,647
*
Annual Income
*
Plus $7,696 for each family member in excess of eight
Zip
7.5K
Internal Use Only
Student Confirmation (all fields are required)
Questions? Call the Recruitment Response Center at 1.800.342.3811, Monday-Friday, between 8:30 a.m. and 4:30 p.m. (EST).
To be considered for an application fee waiver from The State University of
New York, students must:
• Complete and submit the 2016 Fee Waiver Request Form (this form)
with required signatures. Other acceptable fee waiver forms include an
A
CT or SAT fee waiver (not registration card) or other official form from
a recognized community agency such as the Urban League.
• Be a resident of New York State or a citizen of the United States.
• Meet the financial eligibility criteria shown in the table to the right.
If eligibility is confirmed, the Application Services Center will grant an application
fee waiver for the first four (4) campus choices selected.
Option 1: Counselor/Advisor Certification
To the best of my knowledge, the student meets the requirements outlined on this fee waiver form. I have confirmed with the
student that this request is applicable for up to four (4) campus choices and appropriate processing fee(s) for additional campus
choices should be submitted with the application. The student is aware that financial documentation in support of this fee waiver
may be requested.
School Counselor/Transfer Advisor Signature: Date:
High School/College:
Option 2: Proof of Income
Students who are unable to obtain a School Counselor or Transfer Advisor signature, must provide proof of income and attach a
copy to this form. Proof of income may include any one of the following:
• Most recent federal tax return • Statement of Social Services benefits
• Student Aid Report (SAR) from the FAFSA • Proof of unemployment insurance benefits
Applicant ID Number: U.S. Social Security Number: - -
Name: //
Address:
Phone Number: Date of Birth:
City State
Name
Phone Number
(
including area code):
L
ast First Middle
Street/P.O. Box Apt #
C
ity State/Province Zip/Postal Code Country
