GENERAL
Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents
Downloadable File MS Word (27 KB)

To:Registrar
[Postsecondary Institution]
From:___________________________________________________
Student's First Name      Middle Initial      Last Name

___________________________________________________
Permanent Street Address      City     State     Zip Code

Under the Family Educational Rights and Privacy Act (FERPA), the [Postsecondary Institution] is permitted to disclose information from your education records to your parents if your parents (or one of your parents) claim you as a dependent for federal tax purposes. Please indicate whether your parents claim you as a tax dependent.

Please check the appropriate box:

Yes. I certify that my parents claim me as a dependent for federal income tax purposes.

No. I certify that my parents do not claim me as a dependent for federal income tax purposes.

Signature: ___________________________ Date: ______________

If you are not claimed as a dependent or you do not know whether you are claimed as a dependent for federal income tax purposes, but you agree that [Postsecondary Institution] may disclose information from your education records to your parents, please sign the following consent:

I consent to the disclosure of any personally identifiable information from my education records to my parent(s), for reasons determined by the [Postsecondary Institution] as appropriate. This authorization will remain in effect for the [2008-2009] school year.*

Signature: ___________________________ Date: ______________

If parents live at the same address, please list both in # 1.

1. Name(s)  __________________________________________

Address  _____________________________________________

City, State, Zip  __________________________________________________

Telephone  ___________________________________________



2. Name(s)  ___________________________________________________

Address  ______________________________________________

City, State, Zip  ___________________________________________________

Telephone  ____________________________________________

*Students cannot be denied any educational services from the [Institution] if they refuse to provide consent.


 
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Last Modified: 12/12/2007