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School Year:
Date:
All information provided in connection with this application will be kept confidential.
Name of Student:
Grade:
Building:
Name of Parent/Guardian (Or legal/actual custodian):
Address:
Please check type of waiver desired:
_____Full Waiver
_____Partial Waiver
_____Temporary Waiver
Please check if the student of the student's family meets the financial eligibility criteria or is involved in one of the following programs:
Full Waiver
_____Free meals offered under the Children Nutrition Program
_____Family Investment Program (FIP)
_____Supplemental Security Income (SSI)
_____Transportation assistance under open enrollment status
_____Foster care
Partial Waiver
_____Reduced priced meals offered under the Children Nutrition Program
Temporary Waiver: If none of the above apply but you wish to apply for a temporary waiver of school fees because of serious financial problems, please state the reason for the request. _____________________________________________________________________________________
Signature of Parent/Guardian (or legal/actual custodian):
Note: Your signature is required for the release of information regarding the student or the family's financial eligibility for the programs checked above.
Administrative Action: _____Approved _____Denied
By:
Date:
Completed fee waiver forms shall be filed annually and will remain on file in the school office for five years.
Please return this form to:
Linn-Mar Community School District
Business Office
3556 Winslow Road
Marion IA 52302
Reviewed: 7/13; 10/14; 11/17; 12/20
Revised: 10/23; 9/24
Related Policy: 505.3; 505.3-R