Fee Waiver Eligibility Checker

Fee Waiver Eligibility Checker
According to COMAR 10.25.05.12 (G), the Executive Director of the MHCC may grant a partial or full waiver of fees for requested data if:

(1) An applicant submits a written request for partial or full waiver of fees detailing reasons for the waiver request and, if applicable, amount of partial waiver requested;

(2) An applicant provides financial statements or any other supporting documentation requested by the Executive Director regarding the applicant's inability to pay required fees;

(3) An applicant is a recipient of monetary funds from a funding source that covers all or part of the costs of an applicant's use of the data, and the applicant provides the specified documentation.

(4) An applicant timely provides any other information and documentation requested by the Executive Director; and

(5) After considering all information provided by an applicant in support of a full or partial fee waiver, the Executive Director determines that a full or partial waiver of fees is in the public interest.
Please confirm below that the Applicant can meet all of the Applicant requirements above to be considered for a partial or full fee waiver in 10.25.05.12 (G).

Confirm

Fee Waiver Request
Maryland Health Care Commission

Attn: Mahlet Konjit-Solomon

Chief, APCD Public Reporting and Data Release

4160 Patterson Avenue

Baltimore, Maryland, 21215
Date

MonthDayYear
Date
Re: MCDB Data Request Application: Request for Fee Waiver for Research Project entitled,
" Project Title "

This is to request that the Commission grant a waiver of the non-profit/academic fee of $3000 per MCDB data file per year for the four data files that we are requesting for the above-referenced research project. We are requesting the Data Being Requested . The research project is planned for Number of Years. Thus, the total fees for the requested MCDB data would be Total Fees for Requested Data.
We are requesting a waiver of these fees...
Describe the reason for the fee waiver request, please refer to COMAR 10.25.05.12 (linked on previous page)
Sincerely,

Clear
Print Name

First NameLast Name
Title
Title at Requesting Organization

Fee Waiver Request Documentation & Supplemental Information
COMAR 10.25.05.12.(G)(2) An applicant provides financial statements or any other supporting documentation requested by the Executive Director regarding the applicant's inability to pay required fees

Please upload any financial statements or other supporting documentation you would like to be considered with your request for a partial or full fee waiver.
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COMAR 10.25.05.12(G)(3) An applicant is a recipient of monetary funds from a funding source that covers all or part of the costs of an applicant's use of the data, and the applicant provides documentation of: SEE BELOW.

I am a recipient of monetary funds from a funding source that covers all or part of the costs of our requested use of the data.I am NOT a recipient of monetary funds from a funding source that covers all or part of the costs of our requested use of the data
COMAR 10.25.05.12(G)(3) An applicant is a recipient of monetary funds from a funding source that covers all or part of the costs of an applicant's use of the data.

I am the recipientI am not the recipient
COMAR 10.25.05.12(G)(3.a) The applicant provides documentation of the written proposal requesting funding submitted to a funding source.

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COMAR 10.25.05.12(G)(3.b) A funding source's response to an applicant's request for funding and, if applicable, funding approval

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COMAR 10.25.05.12(G)(3.c) Any requirements, including data sharing, imposed by a funding source as a condition of receipt of funding

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COMAR 10.25.05.12(G)(3.d) The budget governing an applicant's use and allocation of the monetary funds that a funding source has granted or given to an applicant

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(OPTIONAL) Any additional documentation the applicant would like to provide to support their request for a full or partial fee waiver.

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(OPTIONAL) In the space below, please describe how your request for a full or partial fee waiver falls within public interest.
Should be Empty:

Fee Waiver Eligibility Checker

Fee Waiver Request

Fee Waiver Request Documentation & Supplemental Information