|MS Word (26 KB)|
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 parents live at the same address, please list both in # 1.
1. Name(s) __________________________________________
City, State, Zip __________________________________________________
2. Name(s) ___________________________________________________
City, State, Zip ___________________________________________________