Fee Waiver Application Student Name:* First Last Student Number: This is your student's 9 number. I f you don't know it, that is OK.Address:* Street Address City ZIP / Postal Code Grade Level:* 7th 8th 9th Parent/Guardian Name:* First Last Phone:*Email:* Please check if applicable:* Student is eligible based on income verification (see table below) Student receives (SSI)* Supplemental Security Income (qualified child with disabilities) Family receives TANF (currently qualified for financial assistance or food stamps) Student is in Foster Care (under Utah or local government supervision) Student is in State Custody Parent(s)/guardian(s) will need to produce supporting documentation for each category that applies. *Students who receive survivor benefits do not qualify for the SSI category listed above Income Verification Table (Click to Enlarge): Parent(s)/guardian(s) shall provide income eligibility documentation in the form of income tax returns or current pay stubs demonstrating compliance with requirements consistent with state law and school district policies and/or guidelines for all qualifiers. If none of the above apply, but you wish to apply for fee waivers or other help with school fees because of serious financial problems, please state the reason(s) for the request.Fees:Please check the school fee schedule and list all fees that you wish to have waived. If your student is eligible for fee waivers, all of those fees will be waived. [Please note that costs for yearbooks, class rings, letter jackets, school pictures, and similar items are not fees and will not be waived. Students may be required to pay fees for concurrent enrollment or advanced placement courses. The portion of the fees related specifically to college or post-secondary grades or credit is not subject to fee waiver.] If you wish to have all applicable fees waived, please check "All Fees." All Fees Basic Fee - $59 7th grade CTE Intro - $10 Science Fee - $10 Other Elective Fees (vary from $5 - $15) Total number of ALL PEOPLE living in the household: 1 2 3 4 5 6 7 8 Household Member #1Name of Household Member #1* First Last Monthly earnings from work (before deductions) of Job 1 for household member #1:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #1:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #1:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #1:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #1:Household Member #2Name of Household Member #2* First Last Monthly earnings from work (before deductions) of Job 1 for household member #2:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #2:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #2:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #2:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #2:Household Member #3Name of Household Member #3* First Last Monthly earnings from work (before deductions) of Job 1 for household member #3:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #3:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #3:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #3:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #3:Household Member #4Name of Household Member #4* First Last Monthly earnings from work (before deductions) of Job 1 for household member #4:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #4:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony child support for household member #4:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #4:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #4:Household Member #5Name of Household Member #5* First Last Monthly earnings from work (before deductions) of Job 1 for household member #5:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #5:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #5:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #5:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #5:Household Member #6Name of Household Member #6* First Last Monthly earnings from work (before deductions) of Job 1 for household member #6:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #6:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #6:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #6:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #6:Household Member #7Name of Household Member #7* First Last Monthly earnings from work (before deductions) of Job 1 for household member #7:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #7:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #7:*TANF payments, welfare payments, alimony, and child support paymentsMonthly ther income, 2nd job, etc. for household member #7:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #7:Household Member #8Name of Household Member #8* First Last Monthly earnings from work (before deductions) of Job 1 for household member #8:*Wages, salaries and tips, strike benefits, unemployment comp., workers’ comp, net income from self-owned business or farmMonthly pension, retirement, social security for household member #8:*Pensions, supplement, security income, retirement payments, Social Security Income (including SSI a child receives)Monthly welfare, alimony, child support for household member #8:*TANF payments, welfare payments, alimony, and child support paymentsMonthly other income, 2nd job, etc. for household member #8:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties and annuities; net rental income; any other incomeTotal monthly income for household member #8:Total monthly income for entire household:SignatureA parent/guardian must apply for a fee waiver within thirty (30) school days after the first day of school. A student who enters the school any time during the school year also has thirty (30) school days in which to apply for a fee waiver. A student whose family has a financial emergency caused by job loss, major illness or other substantial loss of income, has thirty (30) school days from the qualifying event in which to apply for a fee waiver. In this case only those fees assessed after application has been made will be waived. Fees paid previously will not be reimbursed. All fee payments will be suspended until the school has determined if your student is eligible for fee waivers. You will then be given a written notice of that decision. The school shall require you to prove eligibility. State law requires schools or school districts to require DOCUMENTATION of fee waiver eligibility if parent must “apply for fee waivers.” State law also requires that school districts provide alternatives in lieu of fee waivers, “to the fullest extent reasonably possible according to individual circumstances of both fee waiver applicant and school,” consistent with local board policies and/or guidelines which may include tutorial assistance to other students, assistance before or after school to teachers and other school personnel on school related matters, and general community or home service. If your student is eligible for a waiver, the school cannot require you to agree to an installment payment plan or sign an IOU in place of a waiver.I HEREBY CERTIFY THAT THE INFORMATION AND DOCUMENTATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I ALSO GIVE SCHOOL OFFICIALS PERMISSION TO USE THIS FORM AS A RELEASE TO OBTAIN INFORMATION NECESSARY FOR VERIFICATION OF ELIGIBILITY.* Parent digital signature (Please type your name)Date: MM slash DD slash YYYY DocumentationTo complete the application process, parent(s)/guardian(s) shall provide income eligibility documentation in the form of income tax returns or current pay stubs demonstrating compliance with requirements consistent with state law and school district policies and/or guidelines for all qualifiers. This can be brought to West Lake during the initial registration event on August 9th from 9:00 AM to 3:00 PM, or August 10th from 12:00 PM to 6:00 PM, or during office hours after that. Also, a digital file or picture of the documentation can be uploaded to this form (below). In lieu of income verification, parent(s)/guardian(s) may bring supporting documents to the school for each special category that applies. For TANF (financial assistance or food stamps) attach a letter of decision covering the current period from Workforce Services. For SSI (QUALIFIED CHILD WITH DISABILITIES), attach the benefit verification letter from Social Security. For State custody or foster care, provide the “youth in custody required intake form” and/or “school enrollment letter” provided by the case worker from DCFS or Juvenile Justice Department. This form and all supporting documents will be destroyed after the approval process is complete.Documentation Upload (Front)Max. file size: 12 MB.Documentation Upload (Back - If Needed)Max. file size: 12 MB.FileMax. file size: 12 MB.