Read Microsoft Word - FERPAfordependents.rtf text version

Date: ____________________

Dr. David Weissenburger, Ph.D. Associate Vice President for Enrollment Management Tarleton State University Box T-0620 Stephenville, TX 76402 Dear Dr. Weissenburger, Under federal legislation, the "Family Educational Rights and Privacy Act of 1974," I understand that if my son or daughter is carried as a dependent for federal income tax purposes, I am entitled to request certain student data, such as grades, dates of attendance and other records under the custody of the Office of the Registrar at Tarleton State University. Therefore, as of this date, I, __________________________________,

(Please print your name)

certify that _________________________________, _______________________,

Please print full name of student Social Security Number

(_________________) is carried as a dependent on my Internal Revenue Service

Date of Birth

federal tax form. A copy of the latest IRS federal tax form is enclosed (the dollar amounts can be marked out; just be sure that the name shows as a dependent). I further certify that when I cease carrying the above named student as a dependent for federal tax purposes, I will immediately notify your office in writing. If my son or daughter is not carried as a dependent for federal tax purposes, I understand that the only way I can receive this information is for him or her to request, in writing, that your office send this information to me. (If such is the case, I need not return this form.) Having certified above that my son/daughter is carried as a dependent, I would like to request a copy of the following record(s): __________________________________________________________________________________ _____________________________________

Please sign


Street or Box No.


City, State, Zip


Microsoft Word - FERPAfordependents.rtf

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