RHS - International Baccalaureate Fee Waiver Program

2017–18 Student Eligibility Verification

I. Student Information

Last Name / First Name / MI / Grade / Date
High School of Attendance / Rowland High School

II. The student qualifies for the IB Test Fee Program

Household income does not exceed 185 percent of the federal poverty income guidelines (see Income chart below). Annual gross or total income level is used to determine eligibility (if you are using a U.S. Individual Income Tax Return Form 1040, refer to line 22; line 15 on the 1040A; and line 6 on the 1040EZ). This category includes students who are eligible to participate in the Federal Free and Reduced Price Meal Program.

Students are eligible for the IB Exam fee reduction if:

·  The student is either enrolled or eligible to participate in the Federal Free or Reduced-Price Lunch Program

·  Their family’s income is at or below 185 percent of the poverty level issued annually by the U.S. Department of Health and Human Services, or

·  They qualify as an “identified student” because they are:

o  In foster care or Head Start,

o  Or homeless or migrant, or

o  Living in households that receive SNAP/Food Stamps, TANF cash assistance, or the Food Distribution on Indian Reservations benefits.

·  The student is enrolled in a federal, state, or local program that aids students from low-income families (e.g., Federal TRIO programs such as Upward Bound).

·  The student’s family receives public assistance.

·  The student lives in a federally subsidized public housing or a foster home, or is homeless.

·  The student is a ward of the state or an orphan.

Income Eligibility Guidelines

Size of Family Unit / Annual Family Income*
1 / $21,978
2 / $29,637
3 / $37,296
4 / $44,955
5 / $52,614
6 / $60,273
7 / $67,951
8 / $75,647
Each additional family member add: / $7,696

If the student’s family’s income did not exceed the amount listed in the appropriate row and column, he or she qualifies for an IB Exam fee reduction. The figures shown under family income represent amounts equal to 185 percent of the 2016-17 federal income poverty guidelines established by the U.S. Department of Health and Human Services. These levels were published in the Federal Register, Vol. 81, No. 81, 3/23/16, p. 15503.

III. Verification of Need – Family or Student (18 years or older, not a dependent)

I certify need for financial assistance to pay for the IB exam fees and that our household income during the preceding year did not exceed 185 percent of the federal poverty income guidelines.
Please provide a form of income documentation listed below.
______
Signature of Parent/Guardian or Student Date
For School Use Only – Review income documentation and identify source.
Government agency – Department of Social Services, Social Security Administration, etc.
Most recently filed federal income tax return
Pay receipts
Parent/student statement
Free/Reduced Price Meal Verification
Other – specify:
______
Signature of Designated School Personnel Date

Please do not pay any fees until your application for a fee waiver has been approved.

Please allow up to one week for notification of approval or denial of the fee waiver.

Student/Parent Contact Information

Address:

Street Number Street Name Apt. # City State Zip Code

Phone: ( )

Email:

IB Test Fee Reduction Costs to students for 2017-2018

·  IB Registration - $30 per student – only 11th graders or IB Course Candidates pay a registration fee

·  IB Exams - $5 per exam

Please make checks payable to Rowland ASB and return the receipt to the IB Coordinator