Who can request an application fee waiver?

Candidates who meet an eligibility criterion listed on the form, such as unemployment with primary household responsibility or a listed public assistance status, can request a waiver.

What information does the form ask for?

It asks for examination numbers, titles and dates, applicable eligibility information, the candidate’s name and Social Security number, and a signature and date.

Do I need a notary for the Application Fee Waiver Request and Certification Form?

No. The candidate signs and dates the form without a notary. Applicants claiming unemployment and primary responsibility for household support are asked to provide proof of documentation.

Jefferson County, NY · Jefferson County

No notary required

Application Fee Waiver Request and Certification Form

This form lets candidates request a waiver of civil service examination application fees by certifying that they meet an eligible financial or household circumstance.

At a glance

Issued by: City of Jefferson County · Jefferson County, Jefferson County, New York
Notarization: Not required: file this form without a notary.
Official source: jeffersoncountyny.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

Candidates use this form to request a waiver of application fees for listed civil service examinations under the eligibility criteria stated on the form. It asks for examination details, the candidate’s name, Social Security number, signature, and date, along with the applicable eligibility certification. Applicants claiming unemployment and household responsibility are asked to provide proof of documentation.

Who needs it

Candidates requesting a civil service examination application fee waiver because they meet one of the eligibility criteria listed on the form need this document.

How to submit it

Submit it to the county department named on the form; check the county website for current contact details.

About notarization

This request is signed and dated without a notary; applicants claiming unemployment and household responsibility are asked to provide proof of documentation.

How to submit this form

1
Download the Form
Download the Application Fee Waiver Request and Certification Form.
2
Complete the Examination Details
Enter the examination number, title, and date for each examination listed.
3
Certify Your Eligibility
Check the applicable eligibility boxes and provide any requested public assistance case number.
4
Sign and Submit
Print your name, provide your Social Security number, sign and date the form, and submit it to the county department named on the form.

Frequently asked questions

Who can request an application fee waiver?: Candidates who meet an eligibility criterion listed on the form, such as unemployment with primary household responsibility or a listed public assistance status, can request a waiver.
What information does the form ask for?: It asks for examination numbers, titles and dates, applicable eligibility information, the candidate’s name and Social Security number, and a signature and date.
Do I need a notary for the Application Fee Waiver Request and Certification Form?: No. The candidate signs and dates the form without a notary. Applicants claiming unemployment and primary responsibility for household support are asked to provide proof of documentation.
How do I submit the Application Fee Waiver Request?: Submit it to the county department named on the form; check the county website for current contact details.

Need something notarized?

This Application Fee Waiver Request and Certification Form doesn’t need a notary, but if you have another Jefferson County form that does, a commissioned online notary can help.