Fillable AR Info Rel Auth Form Save (Idaho State University)

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AR Info Rel Auth Form Save (Idaho State University)

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The AR Info Rel Auth Form Save (Idaho State University) form is 1 page long and contains:

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  • 4 check-boxes
  • 17 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Idaho State University

BROWSE IDAHO STATE UNIVERSITY FORMS

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921 S 8th Ave Stop 8219, Pocatello, ID 83209-8219 Ph:
208-282-3000 Fax: 208-282-4701
Website: http://www.isu.edu/finserv/studentfs.shtml
Email: stufees@isu.edu.
In accordance with the Family Educational Rights and Privacy Act (FERPA), also known as the Buckley
Amendment, I, the undersigned, hereby authorize Idaho State University, Student Financial Services personnel to release
financial information contained in my Student Account, and discuss information for the purposes of understanding and meeting
university related financial obligations with me (the student) as well as the person(s) listed on this form.
1.
_____________________________________________ ____________________________________
(Print Name) (Relationship)
2. _____________________________________________ ____________________________________
(Print Name) (Relationship)
3. _____________________________________________ ____________________________________
(Print Name) (Relationship)
4. _____________________________________________ ____________________________________
(Print Name) (Relationship)
I have the right not to consent to the release of my records;
I have the right to review these records upon request;
I have the right to dispute items which I believe to be inaccurate;
This release will remain in effect until a written and signed revocation is delivered to the
Student Financial Services Office. Please consult the Notification of Student Rights Under FERPA to
understand your rights and responsibilities with regard to your account at Idaho State University.
_____________________________________________________ ___________________________________________
(Print Student Name) (Student ID #)
______________________________________________________ ___________________________________________
(Student Signature) (Date)
This information is released subject to confidentiality provisions of the appropriate state and federal laws and regulations
which prohibit any further disclosure of this information without the specific written consent of the person to whom it
pertains, or as otherwise permitted by such regulations.
IDAHO STATE UNIVERSITY
STUDENT FINANCIAL SERVICES
STUDENT INFORMATION RELEASE AUTHORIZATION
Authorize Release of Information
Revoke Release of Information
My financial aid and scholarship records, including processing and eligibility status as well as award types and
amounts. This information will not include specific parental income or asset information.
My university tuition billing account and statements, including credits and debits posted to that account and any
refund amounts I may have received.
My university room and board, student health center charges, parking fines, late fines and any other
financial obligations, which may include amounts owed as well as amounts paid.
This authorization form does not allow the University to release specific academic information.
I further understand:
I understand that anyone requesting information about my account must provide the full student identification
or Bengal ID number at the time they are making their request in order for any information to be released.
3. _____________________________________________ ____________________________________
(Print Name) (Relationship)
4. _____________________________________________ ____________________________________
(Relationship)
right
no
t
to
consent to
e
releas
e
of
my
record
s;
right
to
review
these
r
ecords
upon
request;
right
to
dispute
items
which
I
believe
to
b
e
inaccurate;
will
remain in effect until
a
written and signed revocation is
delivered
to the
financial aid and scholarship
records, including
processing and eligibility status
as
well as award types and
This information will
n
o
t include specific parental income or asset
information.
My university tuition
b
illing account and statements, including credits and
d
ebits posted to that account and
efund amounts I may have received.
My university room and board, student health center charges, parking
fines, late
fines and
any other
ancial obligations, which may include amounts owed as well as a
mounts paid.
This authorization form does not allow the
University to release specific academic information.
derstand that anyone requesting information
about my account must provide the full student
identification
number at the time they are making their request in order for
any information to be released.
I understand that the person(s) listed on this form will have access via telephone, in person, mail, or fax to the
information that may include the following:
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AR Info Rel Auth Form Save (Idaho State University)

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Completed 24 July 2020

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