I am applying for a waiver of occupational fees charged by the Missouri Department of Commerce & Insurance under § 324.015. I understand that this waiver is limited by the scope of § 324.015 and that the Department is not authorized to waive fees charged by other entities or agencies.

(if applicable)
e.g., (573-555-1212)
Address
Business Information
(if applicable)
Business Address

I certify that I qualify for a fee waiver as a “low income individual” as that term is defined in § 324.015.1(3). Specifically, I certify the following: 

(select all that apply) 

I am requesting a fee waiver per the provisions of 324.015 RSMo, I have not received a fee waiver from this agency before, and I certify under penalty of perjury that all information provided is true and accurate to the best of my knowledge and ability.

Note: An individual shall be eligible to receive only one waiver from the department. Providing false information could lead to revocation of your license.

 Section 324.015 may be found online from the Missouri Revisor of Statutes (link) and is also published in the Missouri Revised Statutes Cumulative Supplement 2018. 

I am a member of a household whose household adjusted gross income is below one hundred thirty percent of the federal poverty line. Find the US Federal Poverty Guidelines here.

I am enrolled in a state or federal public assistance program.
(check all that apply)

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