Otherwise - You must bring in your: following items that apply:

The fee waiver application process must be done in person in the office – DO NOT mail in waiver applications. The following sources are considered when computing the total GROSS annual income. NOTE: If you have a Direct Certification LETTER from the State, or a state agency, indicating that you receive SNAP or TANF assistance – bring the letter in. No other documentation is required.

Otherwise - You must bring in your:  Personal Tax Return (e.g. IRS Form 1040) for all persons in the household for calendar year 2016  with supporting W-2 documents and  Current pay stub(s) and/or other documentation for all persons in the household for all following items that apply: EARNINGS FROM WORK  Strike benefits  Unemployment compensation  Worker’s compensation  Net income from self-owned business WELFARE/CHILD SUPPORT/ALIMONY  Public assistance payments  Welfare payments  Alimony/child support payments PENSIONS/RETIREMENT/SOCIAL SECURITY  Pensions  Supplemental security income  Retirement income  Veteran’s payments  Social Security OTHER INCOME  Disability benefits  Cash withdrawn from savings  Interest/dividends  Income from estates/trusts/investments  Regular contributions from persons not living in the household  Net royalties/annuities/net rental income  Any other income

APPLICATION FOR WAIVER OF FEES COMMUNITY HIGH SCHOOL DISTRICT 99 2017-18 School Year

In order to be considered for a waiver of fees the parent or guardian must complete this form along with documentation of income and return it to the school. Please note: only curricular fees can be waived. Reason for this request: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Total Gross Monthly Income (all sources): _________________ Number of Household Members supported by monthly income: _________ Documentation of Income is required STUDENT NAME (Please print) (Last)

(First)

(YIS)

I.D. #

FEES

__________________________________________________

___________

____________

___________________________________________________

___________

____________

__________________________________________________

___________

_____________

__________________________________________________

___________

_____________

Maximum allowable income level for fee waiver requirement 2015-16 Household Size

Annual

Monthly

Twice Per Month

Every Two Weeks

Weekly

1 2 3 4 5 6 7 8 For each additional family member, add:

15,768 21,112 26,546

1,307 1,760 2,213 2,665 3,118 3,571 4,024 4,477 453

654 880 1,107 1,333 1,559 1,786 2,012 2,239 227

603 812 1,021 1,230 1,439 1,648 1,857 2,066 209

302 406 511 615 720 824 929 1,033 105

31,980 37,414 42,848 48,282 53,716 5,434

 Approved __________________________________ Approver Signature

_________________ Date