Request an ACT Fee Waiver

Request an ACT fee waiver: Fee waivers are for need based students and can be obtained from the MSA Counselor once requested.

Student Name: Student ID: Student's UTRGV Email: Student Address: City: State:Zip Code: Phone: Date Requested: Date Needed:

Time Needed: 10:00 AM
3:00 PM

Do you reside in a foster home, are a ward of the state, or are homeless? Yes
No

Does your family receive low-income public assistance or live in federally subsidized public housing? Yes
No

Is your family’s total income at or below the USDA levels for free or reduced-price lunches listed in the chart below? Yes
No

Number in Household (including student):	Total Annual Income before Taxes (in last calendar year):
1	$21,775.00
2	$29,471.00
3	$37,167.00
4	$44,863.00
5	$52,559.00
6	$60,255.00
Each additional	plus $7,696.00 each

I am a MSA student on the:Please check this box to acknowledge all information provided is true: