Exam Fee Waiver Request

EXAM APPLICATION FEE WAIVER REQUEST AND CERTIFICATION FORM

City of Rochester, Department of Human Resource Management, 585.428.7115

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 for the examination listed below be waived in accordance with Section 50.5(b) of the State Civil Service Law.  

 Examination Title                                                            Exam No                                         Examination Test Date

                             Tuesday, May 31, 2011  

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. 

        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 Workforce Investment Act (WIA) eligible through a State or local social service agency (such as 
             Rochesterworks! or B.E.S.T.)

**************************************************************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 if I make any false statement regarding my eligibility for application fee waiver. 

Candidate Information:

First Name             Last Name    

Address                        

City                  State         Zip    

Last 4 digits of Social Security Number    
(To be used to match this waiver with your application.)

Email Address    

NOTE - Submitting this Waiver Request is not a substitution for an Employment Application.  If you have not already done so, you need to submit an application for the exam you wish to participate in.