Model Form for Disclosure to Parents of Dependent Students

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


1.  __________________________________________ 2.  ______________________________

            Name(s)                                                                                   Name(s)

____________________________________________    ________________________________

            Address                                                                                   Address

____________________________________________    ________________________________

            City, State, Zip                                                                       City, State, Zip

____________________________________________    ________________________________

            Telephone                                                                                Telephone