ࡱ> 130#` bjbj 1*******> >|h  $hL\!* !** 6 * * } ** Y=< 0  L0| ,  * $ !! | >>>D >>> >>>****** Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents To: Registrar, [Postsecondary Institution] From: __________________________________________________________________ Students 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.  jrhPs6CJ] hPs6] hPs5\hPs <ghi  Z   \ ]    h^h & F ^` #$ijnUpq/ 01h/ =!"#`$`% @@@ NormalCJ_HaJmH sH tH DAD Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List 6>@6 Title$a$ 5CJ\H@H ZN Balloon TextCJOJQJ^JaJ <ghiZ\]#$ijnUpq00000000000000000 00 00000000000000000000000    ;<fiY\[]"$hjmoTVoqgc,>4808^8`0OJPJQJ^Jo( ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(gc,>>p&         @JZNPs@TTTTT@UnknownGz Times New Roman5Symbol3& z Arial5& z!Tahoma?5 z Courier New;Wingdings" hbfbfbf RR!`xr4d2QHX)?ZN2oModel Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents (MS Word)U.S. Department of Educationcynthia.cabell Oh+'0$LXdt     pModel Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents (MS Word) U.S. Department of EducationNormalcynthia.cabell3Microsoft Office Word@@&<@R[<@#<R՜.+,0t hp  T U.S. Department of Education pModel Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents (MS Word) Title !"#$%&')*+,-./2Root Entry F@@{=<4Data 1TableWordDocument1SummaryInformation( DocumentSummaryInformation8(CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q