Fee Waiver Disqualification Appeal Form
Submit your appeal for a fee waiver disqualification. Please provide accurate information and supporting documents for a timely review.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Waiver/Disqualification Reference Number
*
Reason for Appeal
*
Supporting Explanation
*
Upload Supporting Documents
Upload a File
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Choose a file
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of
Preferred Follow-up/Contact Method
*
Email
Phone
Submit Appeal
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