Southern Ave, Bldg 39, Mesa, AZ 85202 / FAX 480-844-3272 / Submit form via FAX or In-person
Consent to Obtain Credit Report
I, ____________________________________________________, give consent to Mesa Community
College, the U.S. Department of Education, and/or its agents, to access my credit report for the sole
determination of whether I will be approved for a PLUS Education Loan. I understand that I will be notified
of the results of the credit check with respect to my loan application.
Privacy Act Disclosure Notice
rivacy Act of 1974 (5 U.S.C.552a) requires that the following notice be provided to you. The authority for collection the information requested
on this form is §451 et seq. of the Higher Education Act of 1965, as amended. Your disclosure of this information is voluntary. However, if you
do not provide this information, you cannot be considered for a Direct PLUS Loan. The information on this form will be used to determine your
eligibility for a Direct PLUS Loan. The information in your file may be disclosed to third parties as authorized under routine uses in the Privacy
Act notices called “Title IV Program Files” (originally published on April 12, 1994, Federal Register, Vol. 59 p. 17351) and “National Student Loan
Data System” (originally published on December 20, 1994, Federal Register, Vol. 59 p. 65532). Thus, this information may be disclosed to
federal and state agencies, private parties such as relatives, present and former employers and creditors, and contractors of the Department of
Education for purposed of administration of the student financial assistance program, for enforcement purposes, for litigation where such
disclosure is compatible with the purposes for which the records were collected, for use by federal, state, local, or foreign agencies in connection
with employment matters or the issuance of a license, grant, or other benefit, for use in any employee grievance or discipline proceeding in which
the federal Government is a party, for use in connection with audits or other investigation, for research purposes, for purposes of determining
whether particular records are required to be disclosed under the Freedom of Information Act, and to a Member of Congress in response to an
inquiry from the congressional office made at your written request.
Because we request your social security number (SSN), we must inform you that we collect your SSN on a voluntary basis, but section 484(a)(4)
of the HEA (20 U.S.C. 1091(a)(4)) provides that, in order to receive any grant, loan, or work assistance under Title IV of the HEA, a student must
provide his or her SSN. Your SSN is used to verify your identity, and as an account number (identifier) throughout the life of your loan(s) so that
data may be recorded accurately.