Springbrook High School
IB World and Information Technology School
201 Valley Brook Drive
Silver Spring, MD 20904
Main: 301.989.5700  Facsimile: 301.622.1875
IB DP Fee Waiver Certification Form 2016-2017
Student Name:____________________________Grade: _______________ ID:________
The State of Maryland offers a fee-waiver service through a U.S. Department of Education
Federal grant to assist students who qualify.
Student eligibility is determined primarily by membership in a family whose annual income falls
within the guidelines found on the reverse of this page.
If your family does not qualify based upon the guidelines, but there exists extenuating
circumstances that cause a serious financial burden, briefly describe the circumstances on the
lines provided. The school administration will consider the circumstances and determine
eligibility.
I hereby certify that the above named student qualifies for a fee waiver for exam or program costs according
federal eligibility guidelines, or apply for consideration of a waiver due to the circumstances described above.
______________________________________________
Signature of Parent or Guardian
Approved by: __________________
__________________
Date
2016-2017 IB DP Fee Waiver Policy
Criteria:
Students who are eligible for free or reduced-price meals (under the National School Lunch Act),
qualify for a fee reduction on all exams that they take in a given year.
A student qualifies for free or reduced-price lunches if he or she is a member of a family whose
taxable income for the preceding year did not exceed 185 percent of the poverty level as
established by the U.S. Department of Health and Human Services.
The table below lists annual family incomes, by family size, at 185 percent of the poverty level.
If the student’s family income did not exceed the amount listed in the appropriate row and
column, he or she qualifies for a fee reduction.
Income Eligibility Guidelines
(Effective July 1, 2016 through June 30, 2017)
Household Size
Yearly
Monthly
Weekly
1
21,978
1,832
423
2
29,637
2,470
570
3
37,296
3,108
718
4
44,955
3,747
865
5
52,614
4,385
1,012
6
60,273
5,023
1,160
7
67,951
5,663
1,307
8
75,647
6,304
1,455
+7,696
+642
+148
for each additional
family member, add
Alternative Criteria:
Any of the following criteria are allowed by the U.S. Department of Education:

The student’s family receives assistance under part A of Title IV of the Social
Security Act.

The student is eligible to receive medical assistance under the Medicaid program
under title XIX of the Social Security Act.