Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents

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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 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.  __________________________________________       2.  _______________________________

            Name(s)                                                                                   Name(s)

_____________________________________________           ________________________________

            Address                                                                                   Address

_____________________________________________           ________________________________

            City, State, Zip                                                                       City, State, Zip

_____________________________________________           ________________________________

            Telephone                                                                                Telephone

 

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