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FEE WAIVER APPLICATION_Revised Powered By Docstoc
					                                                                                GRADUATE STUDENT ASSOCIATION
                                                               University at Buffalo The State University of New York
                                                                                      310 Student Union, Box 602100
                                                                                             Buffalo, NY 14260-2100
                                                                        Phone: 716-645-2960,  Fax: 716-645-7333


Please be advised that applicants who are granted fee
waivers are no longer eligible for GSA programs or
funds. The programs and funds include but are not
limited to:
Conference Funding        MDRF Research Fund
Editorial Assistance      Childcare Scholarship

I.     Fee Waiver Procedures
       1. Application must be filed with the Graduate Student Association office by

       2. The Graduate Student Association Treasurer will make determination of fee waivers with the
        final decision made by the administrative designee.
       3. A Graduate Student Association officer or designee will verify information given in this
       4. The treasurer of the Graduate Student Association is responsible for notifying the applicant in
       writing regarding the acceptance or denial of his/her application.
       5. In case of denial, the applicant will be advised of the reason in writing by the GSA Treasurer. If
       the applicant wishes to appeal the Treasurer’s determination, s/he must do so by writing to the
       Office of Student Life within 15 days of the dated denial letter. Generally, appeals will be reviewed
       based only upon the information/ documentation submitted to the Graduate Student Association
       with the original application. Student Life will make a final determination, after consultation with
       the GSA Treasurer.

II.    Criteria for Fee Waivers
       1. Eligibility does not necessarily mean a refund will be granted. The GSA only budgets for a
       certain number of waivers each semester.
       2. An applicant whose residence is outside a 75 air-mile radius from SUNYAB’s main campus,
       or, whose academic unit is outside the UB Buffalo complex, may be eligible for fee waivers.
       3. If the applicant earns less than $8,000 (10 months) for a family of three, including at least one
       minor dependent, this is considered financial hardship and the fee will be waived.
       4. Fee waivers may be granted if the student is ineligible for financial aid loans for education and
       is unable to pay the fee without incurring a debt, which would hinder further study. In other words,
       efforts to obtain financial assistance and the ratio of income vs. expenses will be considered in
       the determination of financial hardship.
       5. Fee waivers may be granted on an individual case-by-case basis for those individuals with
       special problems not covered by the above criteria. (See Part III of the application).

III.   GSA Policy for Waiver of Mandatory Student Activity Fee
       - No application will be accepted after the announced deadline
       -   Waivers are granted on a one semester basis only
       -   No waiver shall be granted on the basis of financial hardship unless the student has made an
           application to the Office of Financial Aid for assistance or for educational loans if s/he is
           eligible to do so
       -   No student shall be granted a waiver on the basis of disagreement with any Graduate
           Student Association Policy or non-participation in any GSA sponsored activity, program,
           event, or service
       -   It is the policy of the Graduate Student Association to review all guidelines, procedures, and
           policies for fee waivers every semester at its discretion


General Information to be Filled Out by ALL Applicants.

Semester for which a fee waiver is requested:

Applicant Information:

First Name:                                         Last Name:

Person Number:                       -               E-Mail:

Address:                                                                               Apt. #:

City:                                                   State:                 Zip Code:

Phone :     (Day)                                                    (Night)

Academic Department:                                                  Degree Sought:

Which semester of study are you in?(Circle One) 1 2 3 4 5 6 7 Other (specify)

How many credit hours are you registered for this semester?

        I hereby certify that all information contained herein is correct, to the best of my knowledge. I hereby
authorize the State University of New York at Buffalo to release information to the Graduate Student
Association regarding all given information for the semester for which the fee waiver is being requested. I
understand that distortions of given information are grounds for denial.

          Signature of Applicant:


                                         FOR OFFICE USE ONLY

                          ACCEPTED                          REJECTED

GSA TREASURER’S SIGNATURE                                        DATE

ADMINISTRATIVE SIGNATURE                                         DATE


OUTCOME OF APPEAL:                  ACCEPTED                     REJECTED

          SIGNATURE OF APPEAL’S AUTHORITY                                  DATE


                                         Reasons for Request


Please fill out only the parts, which apply, to you. Make sure you answer all questions in this part. AN

You need only to return the pages that apply to your request – see below

PART I     applies to people who will be registering at SUNYAB, but whose course of study requires them
           to reside more than 75 air-miles from campus (Return pages 2 and 3)

PART II applies to people who have a financial hardship, which prevents them from paying the fee
        (Return pages 2-6)

PART III applies to people having special problems (other than those listed in I & II above) which
         prevents them from paying the fee. People filing under Part III must also fill out Part II to
         receive consideration for a fee waiver (Return pages 2-7)

PART I: Waiver Requested Due to Out-of-Town Residence

1. Will you be living more than 75 air-miles from the SUNYAB campus during you course of study?
                 Yes                               No
2. “Out-of Town” address:
3. Dates you will be residing away from the campus:                           to
4. Describe the project or course of study you will be pursuing away from campus:

5. How many times a week will you be on campus? Explain:

PART II: Waiver Requested Due to Financial Hardship
1. Marital Status:                        Number of dependents:

2. Have you already applied for financial aid for this academic year (i.e., TAP, GSL, NDSL, other loans,
workstudy, etc.                 Yes                               No

3. What type of financial aid have you applied for? Please include verification of application for financial

4. If you answered “NO” to question number two (2), please explain why you did not/cannot apply for
financial aid:

5. Are you a (circle one) GA TA RA MFC Instructor, Other (specify):

6. Do you receive a tuition waiver?                Yes                      No        Amount$

Employment: Applicant:

Are you eligible to work in the United States?                Yes                 No
If no, please explain:

Are you currently employed?                            Yes                   No

If no, why not?

What is the status of your employment?
        _____ permanent/ full time-- beginning date: ___/___/___
        _____ permanent/ part time-- beginning date: ___/___/___
        _____ short term/ full time-- employed from ___/___/___ to ___/___/___
        _____ short term/ part time-- employed from ___/___/___ to ___/___/___

Employer Name:

Employer Address:

Employer Phone: (____) _____-______

Employment: Spouse: (If married, this section must be completed)

Are you eligible to work in the United States? ______Yes      ______No
If no, please explain:

Are you currently employed? ______Yes            ________No
If no, why not?

What is the status of your employment?
        _____ permanent/ full time-- beginning date: ___/___/___
        _____ permanent/ part time-- beginning date: ___/___/___
        _____ short term/ full time-- employed from ___/___/___ to ___/___/___
        _____ short term/ part time-- employed from ___/___/___ to ___/___/___

Employer Name:

Employer Address:

Employer Phone: (____) _____-______

Income: (per year)
                         Applicant   Spouse

Wages, Salaries, Tips,

Stipend: TA/GA/RA


Grants (non-research)


TAP Award

Student Loans

Tuition Waiver

Other Financial Aide

Child Support

Aid From Relatives

Foreign Income

Rental Income

Cash Value of CD's,
Stocks, and Bonds




Total Individual

Total Combined

Expenses: (per year)
                         Household Expenses


Books and Fees






Renter's Insurance

Transportation (car
insurance, gas,
maintenance, bus fare)

Medical Expenses
(insurance and
uncovered expenses)


Child Care

Interest on Loans

Taxes Paid (Last year)




Total Household

PART III. Waiver Requested Due to Special Problems/Circumstances

If you have a specific problem/circumstance other than those mentioned in Parts I & II, please explain
below: (Please be specific and provide reasonable information/documentation for a judgment to be
made) REMEMBER to also complete Part II.