2. Examination Information
4. I Have Signed Up for the Following Exams
6. I Have Taken the Following Exams
8. I request that my application fee(s) for the examination(s) listed below be waived in accordance with Section 50.5(b) of the State Civil Service Law.
10. Exam Number & Title
12. Check the Box(es) That Apply to You

    1. I am currently unemployed and I am primarily responsible for support of a household.
    2. I am currently eligible for Medicaid
    3. I am currently Receiving Supplemental Security Income (SSI) payments
    4. I am currently receiving public assistance
    5. I am currently eligible for Certified Job Training Partnership Act/Workforce Investment Act

    Note: Individuals who can be claimed as a dependent on any other person’s tax return are not eligible for application fee waiver as head of household.
14. If you are receiving public assistance please enter public assistance case number
16. Affirmation
    have read the above portion of Section 50.5(b) of the Civil Service Law relating to the waiver of application fees and certify that I am qualified to receive such waiver for the reasons indicated above. I understand that my claim for application fee waiver may be investigated and I may be disqualified from the listed civil service examination(s) if I make any false statement regarding my eligibility for application fee waiver.
18. Signature
    By typing your name into this field you authorize Yates County to consider this an electronic signature.
19. Date
    Date
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field