Fee Waiver Form

Fee Waiver Form

This form acknowledges that _________________ has been granted a fee waiver. This waiver is for the {Name of Fee} fee, which is at the date of signing an amount of {amount}. The reason for this waiver is {list reason}.

This waiver is conditional, and should certain evidence come to light, the waiver may be revoked. {List special conditions of the waiver here, including reasons it can be revoked}.

This waiver does not imply any future deduction in fees, nor does it imply any obligation to provide future waivers. This waiver will apply only once, and additional waivers must be applied for independently. While every effort will be made to record this exemption, the responsibility for representing proof of the waiver lies with the above signed.

By signing this document, it is agreed that {Fee} will be considered waived according to the conditions listed above.

(Waiver Recipient)		(Date)
(Waiver Provider Representative)		(Date)