STUDENT FEE WAIVER APPLICATION
Banner County School District will waive certain fees for students who qualify for free and reduced lunches under the income guidelines of the United States Department of Agriculture. If you would like the school district to waive specific student fees for your child, you must fill this form out in its entirety and submit it, along with any required documentation, to the office of the Superintendent of Schools prior to the beginning of the activity.
Part 1: Name of the child on who’s behalf you are requesting a fee waiver:________________
Part 2: Specific fee(s) for which you are requesting a waiver:___________________________
Part 3: Eligibility. Select ONE of the following:
a. Check here if your child is eligible for fee waivers because he or she is a foster child. Please attach official documentation from the agency sponsoring the child.
b. Check here if your child is eligible for fee waivers because you receive Food Stamps, FDPIR or TANF for the child.
Please attach a copy of one of the following:
• A Food Stamp, FDPIR or TANF Certification Notice that shows dates of certification
• A letter from Food Stamp or Welfare Office confirming your receipt of Food Stamps, FDPIR or TANF
• An ATP (Authorization to Participate) card with an expiration date. Do not send your EBT card.
c. Check here if you are claiming your child is eligible because your household income is less than 180% of poverty level, please check here.
Please complete the following:
| 1. Name (everyone in your household) | Last month’s income and how often it was received Example: $100/twice a month $100/every other week | Check if no income | |||
| Earnings from work before deductions | Welfare, child support, alimony | Pensions, Retirement, Social Security | Other | ||
| $________/ | $________/ | $________/ | $________/ | ||
| $________/ | $________/ | $________/ | $________/ | ||
| $________/ | $________/ | $________/ | $________/ | ||
| $________/ | $________/ | $________/ | $________/ | ||
| $________/ | $________/ | $________/ | $________/ | ||
| $________/ | $________/ | $________/ | $________/ |
Please attach documents verifying the amount of money your household received last month from each source. The documents you provide must show the name of the person who received the income, the date it was received, how much was received and how often it was received.
Acceptable documentation includes:
Jobs: current paycheck stub or pay envelope that shows how often pay is received; letter from employer stating gross wages and how often they are paid; or business or farming papers, such as a ledger or tax books.
Social Security, Pensions, or Retirement: A notice of eligibility from state employment security office, check stub, or letter from Workers’ Compensation Court.
Welfare Payments: A benefit letter from a welfare agency.
Child Support or Alimony: A court decree, agreement, or copies of checks received.
Other income (such as rental income): Information that shows the amount of income received, how often it is received, and the date received.
No income: A brief note explaining how you provide food, clothing and housing for your household and when you expect an income.
Part 4. Signature and verification
An adult household member must sign this application.
PLEASE READ THIS CERTIFICATION BEFORE SIGNING:
I certify that all information on this application is true and that all income is reported. By my signature on this document, I give school authorities permission to disclose my child’s eligibility for fee waivers to school personnel as necessary to effect the fee waiver. I understand that any clothing, equipment, or other materials used by my child during his or her participation in the activity for which student fees have been waived are and will remain the property of the school district.
Sign here: _____________________________
Date: _____________________
