Student Name:* First Last Student Number: Address:* Street Address City ZIP / Postal Code Grade Level:* 7th 8th Parent/Guardian Name:* First Last Phone:*Email:* Please check if applicable:* Family receives TANF/FEP (Temporary Assistance for Needy Families or Family Employment Program) (financial assistance or food stamps) Student receives Supplemental Security Income (SSI, qualified child with disabilities) Student qualifies for McKinney-Vento Student is in Foster Care (under Utah or local government supervision) Student is in State Custody Student is eligible based on family/household income verification. 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 If none of the above apply, but you wish to apply for fee waivers because of other extenuating circumstances, please state the reason(s) for the request: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 for household member #1:*Disability benefits; cash withdrawn from savings; interest & dividends; income from estates, trusts, and investments, regular contributions from persons not living in the household; net royalties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:SignatureAll fee payments will be suspended until the school has determined if your student is eligible for fee waivers. You will then be given notice of that decision. If your student is eligible for a waiver, the school cannot require you to complete service, 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.* Parent digital signature (Please type your name)Date: MM slash DD slash YYYY DocumentationSubmit the benefit verification from the Utah Department of Workforce Services for the period for which the fee waiver is sought which may be in the form of an electronic screenshot or eligibility determination of status. DocumentationSubmit the benefit verification documents from the Social Security Administration. DocumentationNO DOCUMENTATION NEEDED. McKinney-Vento status will be verified through the district or charters McKinney-Vento Liaison.DocumentationSubmit family income verification in the form of income statements, pay stubs, or tax returns.DocumentationSubmit the youth in care required intake form and school enrollment letter, provided by a case worker from the Utah Division of Child and Family Services or the Utah Juvenile Justice Department. Documentation UploadUpload Document (Front)Max. file size: 12 MB.Upload Document (Back)Max. file size: 12 MB.