Form for Disclosure to Parents of Dependent Students

and Consent Form for Disclosure to Parents

To: Registrar, NCSU

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), NCSU 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 tax purposes.

□ No, I certify that my parents do not claim me as a dependent for federal 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 NCSU 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 NCSU as appropriate. This authorization will remain in effect for the ______________ 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 NCSU if they refuse to provide consent.