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CAYUGA COUNTY APPLICATION FEE WAIVER REQUEST Civil Service Law Section 50.5(b): “…fees shall be waived for candidates who certify to the state civil service department, a municipal commission or regional commission that they are unemployed and primarily responsible for the support of a household, or are receiving public assistance.” I request that my application fee(s) for the examination(s) listed below be waived in accordance with Section 50.5(b) of the State Civil Service Law. Examination Title Exam Number Exam Test Date ELIGIBILITY DOCUMENTATION REQUIRED: If you are applying for application fee waiver, you must submit written documentation that you are eligible for the waiver. It is your responsibility to submit proof of your eligibility. Your claim will be investigated and, if you are found to be NOT eligible, you may be disqualified from participation in the civil service examination. CHECK BOX THAT APPLIES TO YOU AND ATTACH THE APPROPRIATE DOCUMENTATION TO PROVE YOUR ELIGIBILITY. I am currently unemployed and I am primarily responsible for the support of a household. (NOTE: Individuals who can be claimed as a dependent on any other person’s tax return are NOT eligible for application fee waiver as head of household.) If you checked this box, you must include the following documentation: A current Unemployment Insurance Benefits on-line account statement printout verifying that you are unemployed (www.ui.labor.state.ny.us), AND A copy of a bill indicating that you are primarily responsible for the support of a household mortgage statement, rental agreement, etc., in your name). I am currently eligible for Medicaid. If you checked this box, you must include the following documentation: A copy of your current Medicaid card. I am currently receiving Public Assistance (Temporary Assistance for Needy Families / Family Assistance or Safety Net Assistance). If you checked this box, you must include the following documentation: A copy of your current Public Assistance card. I am currently receiving Supplemental Security Income (SSI) payments. If you checked this box, you must include the following documentation: A written letter confirming that you are receiving Supplemental Security Income (SSI) payments. I am certified eligible for Job Training Partnership Act / Workforce Investment Act through a state or local social service agency. If you checked this box, you must include the following documentation: Written certification that you are eligible for Job Training Partnership Act / Workforce Investment Act programs. AFFIRMATION: I have read the above portion of Section 50.5(b) of the Civil Service Law relating to the waiver of application fees and certify that I am qualified to receive such waiver for the reasons indicated above. I understand that my claim for application fee waiver may be investigated and I may be disqualified from the listed civil service examination(s) if I make any false statement regarding my eligibility for application fee waiver. - - Candidate’s Signature Candidate’s Social Security Number (Please Print) Candidate’s First and Last Name Date FOR CIVIL SERVICE STAFF ONLY: I affirm upon receipt of this form that no cash was received. Civil Service Staff Signature: Date: