READMIT APPLICATION FEE WAIVER REQUEST FORM

Readmit applicants to SUNY Plattsburgh who are U.S. Citizens or Permanent Residents, and wish to be considered for a readmit application fee waiver, must submit the following (in addition to this form):

1. A letter requesting a fee waiver along with proof that you meet the income requirements shown in the table below.

2. A copy of your most recent signed Federal Tax Return including all business schedules (if applicable) AND W2 from employer(s); OR, proof that you receive Social Service Benefits, Social Security or SSI, unemployment benefits, etc.

-OR-

3. If you have an extenuating circumstances* and do not feel that you have the ability to pay the readmit application fee.
*You must provide a written statement, addressed to the Director of Admissions, describing the extenuating circumstance for which you are requesting a readmit application fee waiver. The "Applicant Section" must be completed to be considered.
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Financial eligibility is primarily determined by the family income guidelines shown in the table below. These are the same guidelines as those used by the SUNY system.

Household Size: 1 Annual Income: $23,107
Household Size: 2 Annual Income: $31,284
Household Size: 3 Annual Income: $39,461
Household Size: 4 Annual Income: $47,638
Household Size: 5 Annual Income: $55,815
Household Size: 6 Annual Income: $63,992
Household Size: 7 Annual Income: $72,169
Household Size: 8 Annual Income: $80,346

*Plus, 7,992 for each family member in excess of eight.
APPLICANT SECTION
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Banner or NetID:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Number of dependents in household (including head of household):
Total income before taxes (all sources): $ Dollars . Cents
(attach supporting documentation if required)
My signature below confirms that the informations I have provided is accurate. I understand that if my fee is not waived, I am responsible to pay the fee before my application will be reviewed for readmission. The documentation in support of this fee waiver is included along with this form.

Signature of Applicant:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Date Date / MM / DD YYYY

Signature of Head of Household (if different):

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

READMIT APPLICATION FEE WAIVER REQUEST FORM

READMIT APPLICATION FEE WAIVER REQUEST FORM

Financial eligibility is primarily determined by the family income guidelines shown in the table below. These are the same guidelines as those used by the SUNY system.

APPLICANT SECTION