2022-2023 Financial Aid Release of Information Form

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2022-2023 Financial Aid Release of Information Form

AUTHORIZATION TO RELEASE EDUCATION RECORDS TO THIRD PARTIES

Subject to certain exceptions, the Family Educational Rights and Privacy Act (FERPA) requires a student to provide CCAC with written consent before it discloses personally identifiable information (“PII”) from the student’s education records to a third-party. This includes requests to release or discuss PII to or with a parent, attorney or other representative. The written consent must specify the record(s) to be released; state the purpose of the disclosure; and identify the person(s) to whom disclosure may be made. A record of any written authorizations given will be maintained in the education record. In order to authorize CCAC to release PII from your education records, you must complete all fields listed on this form, sign and date it, and return the form to the Office for Registration and Advisement for the campus at which you are enrolled or, in the case of official transcripts, to the College’s Registrar. By completing and signing this form below, you acknowledge that you understand that you have the right to (1) not consent to the release of your education records; (2) inspect any education records released pursuant to this authorization; and (3) revoke this authorization at any time by delivering a written revocation to the College. Please see the College’s FERPA information page (www.ccac.edu/ferpa) and the College’s Board Policy and Administrative Regulations Manuals for additional information.

Student Name:*

First Name

Last Name

Student ID Number:*

Recipient Information:*

First Name

Last Name

Relationship to Student*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

PURPOSE OF DISCLOSURE:*

Family Communication Employment Admission to an Educational Institution Litigation Other (please describe):

Description:*

DESCRIPTION OF RECORDS TO BE RELEASED (check all that apply):*

Academic Information (transcripts, GPA, registration, academic progress, enrollment status) Financial Aid Information (awards, application data, disbursements, eligibility, SAP status) Student Account Information (billing statements, charges, credits, payments, past due amounts; to include pending and award aid) Other (please describe):

Description*

DURATION OF AUTHORIZATION:*

Indefinitely, and until revoked by me in writing From the date of this authorization until:

This authorization will remain effective (please check one)

Date/Time*

Signature*

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