FEE WAIVER REQUEST

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PLEASE PRINT ALL INFORMATION BELOW.
NAME: Print your last name, first name, and middle initial.

Last Name

Income Guidelines

First Name

M.I.

Family Size
(including student)

Maximum
Total Family Income*

1
2
3
4
5
6
7
8
9
10

$29,713.50
$34,590.50
$39,013.50
$41,401.50
$44,918.50
$47,286.50
$49,677.50
$52,057.50
$54,437.50
$56,802.50

PRESENT ADDRESS: Number and Street (include apartment number)

NUMBER AND STREET

CITY

STATE

SOCIAL SECURITY NUMBER

ZIP CODE

DAYTIME TELEPHONE NUMBER

*Including the students income before taxes.

Testing Information

TEST FOR WHICH YOU ARE REQUESTING A FEE WAIVER. ONLY ONE FEE WAIVER GOOD FOR UP TO THREE
TESTS WILL BE ISSUED PER EXAMINEE PER TESTING YEAR
TEST CODE(s)

FEE WAIVER REQUESTS must be received by the appropriate

closing dates shown below. Late or incomplete requests will be
returned unprocessed. Funds may be exhausted prior to the
closing date for the time period you request. If your requirement
for testing allows, you may indicate a second date choice by
checking two boxes below. Please check the box corresponding to
the time period in which you plan to test.

If You Plan to
Test Between:

Closing Date for

Requesting a Fee Waiver

Fee Waiver Request Personal Information*:

SeptemberDecember

(This information must be provided in order for your application to be considered.)

JanuaryMarch

November 26, 2014

1. Family Size (including yourself)

AprilJune

February 11, 2015

2. Number of Dependents
(as defined by Federal Income Tax Form)

JulySeptember

May 20, 2015

Aug
July 23, 2014

Financial Aid Information:

3. Current Education Level

(This section must be completed and signed by

the financial aid director of the institution. The
embossed school seal must be affixed over the
signature or the signature must be notarized in
the appropriate place below.)

4. Tuition for 201415 $

5. Gross Family Income (including your own)
As Reported on the Latest Federal Income Tax Form: $
6. Name of Institution or Agency Requiring Your Scores
(must be an authorized score recipient)

1. Is the examinee receiving financial aid?

[ ] yes [ ] no
2. If yes, how much

7. Name of Institution You Currently Attend

* Information provided on this form is considered confidential.

Mail completed form to:

ETSThe Praxis Series
PO Box 6051
Princeton, NJ 08541-6051

Signature
Institution

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104550-035843 ACCWEBPDF714

3. How will the scores be used?

[ ] admission into teacher education program
[ ] initial certification
[ ] other (briefly explain)