On District Letterhead

[Insert School Year] Waiver of School Fees Application

If you do not automatically qualify you may apply for a waiver if:

1.  Your income qualifies.  Belvidere School District will waive school fees if a parent or guardian meets the current school year income requirements for free meals (100% waiver) or reduced price meals (50% waiver) as annually published by the U.S. Department of Agriculture.  Incomes above the amounts shown on the Income Eligibility Guidelines will not qualify for a fee waiver.

2.  You have special circumstances.  The Business Services office may grant a waiver of fees when one or more of the following factors resulted in the loss or reduction of family income: (a) illness in the family; (b) unusual expenses caused by fire, flood, storm, etc.; (c) seasonal employment; (d) emergency situation; or (e) one or more parent/guardian is involved in a work stoppage.

The following information must be included on all applications: 

•     A copy of the 2014 IRS Federal 1040, 1040A or 1040EZ.  If household members file separate tax returns, copies of both returns must be submitted.

• Names of all household members, including the student(s) and the school(s) they attend. 

• Signature of adult household member. 

•     If your current income is different than that reflected on IRS Federal 1040, please include current income information for each household member listing source of income such as wages, alimony, child support, pension, worker’s compensation, etc., and the frequency in which the income is received (weekly, every two weeks, monthly, or annually), including unemployment payments.

Only one application is needed per household provided all current students are listed on the application.  A new Waiver of School Fees Application must be submitted at the beginning of each school year.  

Please complete the information and return the application and supporting documents to the following address no later than August 28, [insert year]:

Belvidere Community Unit School District #100

Attn:  Business Services Office

1201 Fifth Avenue

Belvidere, Illinois 61008

 

[Insert School Year] FEE WAIVER APPLICATION

I, _____________________________________, being the parent or the legal guardian of the student(s) listed above, hereby request that Belvidere Community Unit School District #100 waive school fees for the following reason:

____The student(s) is eligible pursuant to 105 ILCS 125/1 et. seq.  (SNAP or TANF)

____The student(s) is currently receiving aid under Art IV of the Illinois Public Aid Code (include evidence)

____I am unable to afford the fees due to the following reason(s):  _______________________________________________

____________________________________________________________________________________________________

 The following proof of income for all adult household members is required.  

1.    A copy of your 2014 IRS Form 1040 or Form 1040A or Form 1040EZ.  If you did not file a tax return for 2014 please attach     W-2’s, a letter from your employer on company letterhead stating earnings, last month’s paycheck stubs, or other proof of     income for all adults living in the household.  If household members file separate tax returns, copies of both returns must be     submitted.

2.    If your current income is different than that reflected on the 1040, please include income information for each household     member listing sources of all  income such as wages, alimony, child support,  pension, worker’s compensation, etc., and  the

       frequency in which the income is  received (weekly, every other week, monthly, or annually)  including  any  unemployment 

       received or income that resulted from a change in your circumstances.

 If required income information is not included for all adults the request will not be considered.

Certification:  

I certify that all information contained on this application is true and correct and that all household income has been reported.  I understand that school officials may verify all of the information contained on this application and all information submitted with this application.  I have reviewed the District’s policy regarding Waiver of Student Fees and am aware that supplying false information to obtain a fee waiver is a Class 4 felony pursuant to 720 ILCS 5/17-6.

_______________________________________/______        _____________________________________________

Signature of Parent or Guardian                            Date        Daytime phone number

 A copy of this form will be mailed to you after your application has been processed.  Please print the name/address information legibly as it will be used as your mailing label on correspondence regarding this application.   

Name of Parent or Guardian

 Street Address

 City, State, Zip

Your application has been processed and your request to have fees waived is:                             □ Approved:     100%      50%

    □ Denied:     Income exceeds eligibility

    □ Incomplete - need the following information:

________________________________________         ________________________________________

Date Processed _______________      by _______

important:   Keep this form in your files!

May 2016