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Lorry Johnson Personnel Officer SCHUYLER COUNTY CIVIL SERVICE DEPARTMENT 105 Ninth Street, Unit 21 Watkins Glen, NY 14891 (607) 535-8190 Fax: (607) 535-8193 APPLICATION FEE WAIVER REQUEST AND CERTIFICATION FORM 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 and I am providing documentation to verify my eligibility for a fee waiver. (See list below of approved documentation) Examination Title Exam Number Exam Test Date Check the box(es) below that apply to you: I am currently unemployed and I am primarily responsible for 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. I am currently: Eligible for Medicaid Receiving Supplemental Security Income (SSI) payments Receiving Public Assistance (Temporary Assistance for Needy Families/Family Assistance or Safety Net Assistance): Enter Public Assistance Case Number Certified Job Training Partnership Act/Workforce Investment Act eligible through a State or local social service agency 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 First and Last Name (Please Print) Candidate’s Social Security Number Candidate’s Signature Date Office Use Unemployment/Head of Household Proof of Unemployment (Document proving receipt of Unemployment Insurance benefits) Proof of Head of Household (Income Tax Return) Social Services Proof of Medicaid (Copy of current Medicaid card) Proof of SSI Payments (Document proving receipt of SSI) Proof of Public Assistance (Paperwork from DSS) Proof of Certified Job Training Partnership Act Fee Waiver 1-10.doc