Rate Waiver Approval Form
Submit your request for a rate, fee, or charge waiver. Please provide detailed information and justification for your request.
Applicant Full Name
*
First Name
Last Name
Department or Affiliation
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Rate/Fee to Be Waived
*
Please Select
Service Fee
Late Payment Fee
Processing Fee
Membership Fee
Other
Amount to Be Waived (USD)
*
Reason for Waiver Request
*
Supporting Documentation (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Have you previously requested a waiver for this rate/fee?
*
Yes
No
Recommended Action (for Reviewer)
*
Please Select
Approve Waiver
Deny Waiver
Request More Information
Reviewer Comments
By signing below, I confirm that the information provided in this form is accurate and complete to the best of my knowledge.
*
Submit Request
Submit Request
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