!!1101!Sherman!Drive,!Utica,!NY!13501!
Phone!(315)!792=5336!
Fax!(315)!792=5698!
www.mvcc.edu!
FROM: __________________________________________________________________________
Student’s First Name Middle Initial Last Name
Permanent Address: ________________________________________________________________
Street Address City State Zip Code
Please Check The Appropriate Box:
_______________________________________________________________________________
Student 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 Mohawk Valley Community College may disclose information from your education records to
your parents, please sign the following consent:
I consent to disclosure of any personally identifiable information from my education records to my parents) for reasons
determined by Mohawk Valley Community College as appropriate. This authorization will remain in effect for the
academic year indicated. ( Academic year is calculated as the Fall and Spring and Summer semsesters) A new form must
be filled out for each academic year the student wishes to share information.
_______________________________________________________________________________
Student Signature Date
If parents live at the same address, please list both in #1.
Rec eived!By/Date!_ ___________________! Stamp:!
CONSENT TO
DISCLOSE
INFORMATION
Under the Family Educational Rights and Privacy Act (FERPA) Mohawk Valley Community College 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.
Yes.!I!certify!that!my!parents!claim!me!as!a!dependent!for!federal!income!tax!purposes.!
No.!I!certify!that!my!parents!do!not!claim!me!as!a!dependent!for!federal!income!tax!purposes.!
1. _______________________________
Name(s)
_________________________________
Address __________________________
City ________ State _____ Zip ________
Telephone_________________________
2. ________________________________
__________________________________
Address __________________________
City ________ State _____ Zip ________
Telephone_________________________
Academic Year:______
M
number___________
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signature
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