Model Form for Disclosure to Parents of Dependent Students
Downloadable File MS Word (26 KB)

[Postsecondary Institution]
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)  __________________________________________

Address  _____________________________________________

City, State, Zip  __________________________________________________

Telephone  ___________________________________________

2. Name(s)  ___________________________________________________

Address  ______________________________________________

City, State, Zip  ___________________________________________________

Telephone  ____________________________________________

Print this page Printable view Send this page Share this page
Last Modified: 10/29/2007