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