Form 161Ab – Fill Out and Use This PDF

How do I know if I qualify?

Applicants may request for a Kamehameha Schools (KS) Fee Waiver Code to cover the $20.00 cost of the KS Financial Aid and Scholarship online or paper application. If your household income meets or is below the following income levels, complete the information below and provide a copy of your signed 2009 Federal Income Tax return to the any one of the Kokua locations listed in our Program Guidebook or at www.ksbe.edu/finaid.

Household Size 2009 Income Thresholds: Household Size 2009 Income Thresholds:

When should I request for the Fee Wavier?

Your fee waiver request must be received by the wavier deadline dates below with complete documentation. Mail in requests postmarked after deadlines will be processed, however KS will not be responsible for any late waiver notification to the requestor. Incomplete requests will not be processed.

	Financial Aid and Scholarship Programs		Waiver	Application
			Deadline	Deadline
	Pauahi Keiki Scholars – Kindergarten		2/15/2010	2/27/2010
	Kamehameha Schools Preschool to Grade 12		4/16/2010	4/30/2010
	Pauahi Keiki Scholars Cycle 1	(August 2010 – July 2011)	4/16/2010	4/30/2010
	Pauahi Keiki Scholars Cycle 2	(January 2011 – July 2011)	9/16/2010	9/30/2010

Contact Information

Parent/Guardian A: __________________________________________________ Phone Number: (____) _________

Provide the name of the Parent/Guardian A on your application

I/We will be using this waiver to complete my/our	I/We would like to receive my/our waiver notice by
Online	Mail
Paper Application	Email _______________________________
	Provide valid email address

If by US Mail please provide the following information:

__________________________________________________________________________________________

Mailing Address

City, State

Zip Code

Provide one of your children’s name and the program he/she is applying to:

Child’s Name	Program
______________________________________	______________________________________________

I certify that the information above and the supporting documents provided to Kamehameha Schools are true and correct. I also understand that it is my responsibility to complete and send in this request by the waiver deadline dates.

Parent/Legal Guardian’s Signature:_____________________________________Date:____________________

DOCUMENT NO. 161AB (REVISED 1/13/2010)

Page 1

For Office Use Only

1.Review submitted 20091040 IRS Federal Income Tax Return. Record the number of exemptions and adjusted Gross income below. Attach a copy of the 1st page of applicant’s 1040 Income Tax Return:

	Number of Total	1040 Adjusted Gross
	Exemptions:	Income (AGI)
Form1040	Line: 6d _______________	Line: 37 ____________
Form 1040A	Line: 6d _______________	Line: 21 ____________
Form 1040EZ Line: 6d _______________		Line: 21 ____________

2.Take total exemptions noted above and compare the 1040 AGI. Determine if AGI meets or falls below the income thresholds stated below:

	Household Size	2009 Income	Household Size	2009 Income
		Thresholds:		Thresholds:
	2	38,961	7	78,736
	3	46,916	8	86,691
	4	54,871	9	94,646
	5	62,826	10	102,601
	6	70,781	10+	$102,601 + 7,955 for
				each addition exemption

3.Assign waiver code if applicant’s AGI is at or below the income threshold. Record the waiver code issued and when waiver code was sent or released to the applicant.

Fee Waiver Number: ____ ____ ____ ____ ____ ____ Sent on: __________________________

4. Complete and sign.
______________________________________________	_____________________________________
Print Name of Authorized KS Staff	Signature of Authorized KS Staff
_______________________________________________	___________________	________________
Title of Authorized KS Staff	Phone	Date

Location Waiver Request Accepted/Issued:

Page 2