Form DBPR LI 001 Application for Low Income Waiver of Initial Licensing Fee - Florida

Form DBPR LI001 or the "Application For Low Income Waiver Of Initial Licensing Fee" is a form issued by the Florida Department of Business & Professional Regulation.

The form was last revised in July 1, 2017 and is available for digital filing. Download an up-to-date Form DBPR LI001 in PDF-format down below or look it up on the Florida Department of Business & Professional Regulation Forms website.

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State of Florida
Department of Business and Professional Regulation
Application for Low Income Waiver of Initial Licensing Fee
Form # DBPR LI 001
General Information
This form should be used by applicants requesting a waiver of the initial licensure fee based on their
annual household income, before taxes, being at or below 130% of the federal poverty guidelines
prescribed for the applicant’s family household size by the United States Department of Health and
Human Services. This waiver only applies to the licensing fee; other fees including application and
unlicensed activity fees are still due at time of application. This waiver request is subject to approval by
the Department of Business and Professional Regulation. This form should be attached to your
application for licensure.
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions (by Section)
a. Section I – Applicant Information
i.
Use this form if you are applying to waive your initial licensure fee based on your
household income being at or below 130% of the federal poverty guidelines as set forth in
s. 455.219(7)(a), Florida Statutes.
ii.
A Social Security number is required in order to apply for any individual license within the
Department of Business and Professional Regulation.
iii.
Provide your mailing address and email. This will be used for sending correspondence
regarding your application and license.
iv.
Contact information is often used to quickly resolve questions regarding applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
b. Section II – Fee Waiver Requirement
i.
Complete this section in its entirety.
To determine if you qualify for this fee waiver you may utilize the low-income
calculator and/or matrix located on the Department’s Low Income Individuals Fee
Waiver webpage at:
http://www.myfloridalicense.com/dbpr/LowIncomeFeeWaiver.html.
c. Section III – Affirmation by Written Declaration
i.
Applicant must sign the Affirmation by Written Declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
Please mail your completed application to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
DBPR LI 001 Application for Low Income Waiver of Initial Licensing Fee
Eff. Date July 2017
Incorporated by Rule: 61-35.029
1 of 2
State of Florida
Department of Business and Professional Regulation
Application for Low Income Waiver of Initial Licensing Fee
Form # DBPR LI 001
General Information
This form should be used by applicants requesting a waiver of the initial licensure fee based on their
annual household income, before taxes, being at or below 130% of the federal poverty guidelines
prescribed for the applicant’s family household size by the United States Department of Health and
Human Services. This waiver only applies to the licensing fee; other fees including application and
unlicensed activity fees are still due at time of application. This waiver request is subject to approval by
the Department of Business and Professional Regulation. This form should be attached to your
application for licensure.
Instructions
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center, at 850.487.1395.
1. Application Instructions (by Section)
a. Section I – Applicant Information
i.
Use this form if you are applying to waive your initial licensure fee based on your
household income being at or below 130% of the federal poverty guidelines as set forth in
s. 455.219(7)(a), Florida Statutes.
ii.
A Social Security number is required in order to apply for any individual license within the
Department of Business and Professional Regulation.
iii.
Provide your mailing address and email. This will be used for sending correspondence
regarding your application and license.
iv.
Contact information is often used to quickly resolve questions regarding applications by
telephone call or email. If contact information is not provided, questions regarding
applications will be mailed to the applicant’s mailing address and may take longer to
resolve.
b. Section II – Fee Waiver Requirement
i.
Complete this section in its entirety.
To determine if you qualify for this fee waiver you may utilize the low-income
calculator and/or matrix located on the Department’s Low Income Individuals Fee
Waiver webpage at:
http://www.myfloridalicense.com/dbpr/LowIncomeFeeWaiver.html.
c. Section III – Affirmation by Written Declaration
i.
Applicant must sign the Affirmation by Written Declaration.
ii.
If the applicant fails to sign the affirmation statement, the Department will not process the
application.
Please mail your completed application to:
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-0783
DBPR LI 001 Application for Low Income Waiver of Initial Licensing Fee
Eff. Date July 2017
Incorporated by Rule: 61-35.029
2 of 2
State of Florida
Department of Business and Professional Regulation
Application for Low Income Waiver of Initial Licensing Fee
Form # DBPR LI 001
If you have any questions or need assistance in completing this application, please contact the
Department of Business and Professional Regulation, Customer Contact Center at 850.487.1395.
Section I – Applicant Information
PERSONAL INFORMATION
Social Security Number*
License Applying For:
Last/Surname
First
Middle
Suffix
Birth Date (MM/DD/YYYY)
Gender
 Male  Female
/
/
Email Address:
Phone Number:
Alternate Email Address:
Alternate Phone Number:
MAILING ADDRESS
Street Address or P.O. Box
City
State
Zip Code
County (if Florida address)
Country
* The disclosure of your Social Security number is mandatory on all professional and occupational license applications, is solicited
by the authority granted by 42 U.S.C. §§ 653 and 654, and will be used by the Department of Business and Professional Regulation
pursuant to §§ 409.2577, 409.2598, 455.203(9), and 559.79(3), Florida Statutes, for the efficient screening of applicants and
licensees by a Title IV-D child support agency to assure compliance with child support obligations. It is also required by § 559.79(1),
Florida Statutes, for determining eligibility for licensure and mandated by the authority granted by 42 U.S.C. § 405(c)(2)(C)(i), to be
used by the Department of Business and Professional Regulation to identify licensees for tax administration purposes.
Section II – Fee Waiver Requirement
FEE WAIVER REQUIREMENT
I attest that my annual household income, before taxes, is at or below 130% of the federal poverty
guidelines prescribed by the United States Department of Health and Human Services, as required
in s. 455.219(7)(a), Florida Statutes.
Annual Household
Number of Dependents Claimed on
Income Before Taxes:
Applicant’s Most Recent Federal Tax Return*:
* If you claimed zero dependents please enter one dependent in the space provided. If you have not filed taxes or your number of
dependents has changed since you last filed your taxes please enter your current number of dependents.
Section III – Affirmation By Written Declaration
AFFIRMATION BY WRITTEN DECLARATION
I certify that I am empowered to execute this application as required by Section 559.79, Florida Statutes. I
understand that my signature on this written declaration has the same legal effect as an oath or
affirmation. Under penalties of perjury, I declare that I have read the foregoing application and the facts
stated in it are true. I understand that falsification of any material information on this application
may result in criminal penalty or administrative action, including a fine, suspension or revocation
of the license.
Signature:
Date:
Print Name:
DBPR LI 001 Application for Low Income Waiver of Initial Licensing Fee
Eff. Date July 2017
Incorporated by Rule: 61-35.029

Download Form DBPR LI 001 Application for Low Income Waiver of Initial Licensing Fee - Florida

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