OMB Number: 1810-0021 Expiration Date: 02/29/2020
U.S. Department of Education
Office of Indian Education
Washington, DC 20202
TITLE VI ED 506 INDIAN STUDENT ELIGIBILITY CERTIFICATION FORM
Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the
student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child
cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year.
Where applicable, the information contained in this form may be released with your prior written consent or the prior written
consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family
Educational Rights and Privacy Act, 20 U.S.C. § 1232g, and any applicable state or local confidentiality requirements.
STUDENT INFORMATION
Name of the Child __________________________________________________ Date of Birth ______________ Grade ______
(As shown on school enrollment records)
Name of School ____________________________________________________________________________________________
TRIBAL ENROLLMENT
Name of the individual with tribal enrollment: ___________________________________________________________________
(Individual named must be a descendent in the first or second generation)
The individual with tribal membership is the: _____ Child _____ Child's Parent _____ Child's Grandparent
Name of tribe or band for which individual above claims membership: _______________________________________________
The Tribe or Band is (select only one):
_____ Federally Recognized
_____ State Recognized
_____ Terminated Tribe (Documentation required. Must attach to form)
_____ Member of an organized Indian group that received a grant under the Indian Education Act of 1988
as it was in effect October 19, 1994. (Documentation required. Must attach to form)
Proof of enrollment in tribe or band listed above, as defined by tribe or band is:
A. Membership or enrollment number (if readily available) _____________________________________________________ OR
B. Other Evidence of Membership in the tribe listed above (describe and attach) _______________________________________
Name and address of tribe or band maintaining enrollment data for the individual listed above:
Name ____________________________________________ Address ________________________________________________
City _______________________________State ______Zip Code ____________
ATTESTATION STATEMENT
I verify that the information provided above is accurate.
Name Parent/Guardian ______________________________________ Signature _______________________________________
Address ______________________________________ City ____________________________State ______Zip Code __________
Email Address ________________________________________ Date _______________
Student ID #
0000000
*No Nicknames
*Write the name of person enrolled with the tribe
*Only check one box
*Must write out full name of village or tribe
*Only
check
one
box
*Enrollment # must be provided
*Copy of documentation must be attached
*Address must be for the village or tribe
Not personal address
*Form is void without signature
Jimmy Neutron
07/20/2002
3
Lindberg Elementary
Jimmy Neutron
X
White Mountain Apache Tribe
X
123-45-6789
CIB
Bureau of Indian Affairs 3601 C. St Suite 1100
Anchorage
AK
99504
Judy Neutron
1234 A Street
Anchorage
AK
99508
09/22/17
click to sign
signature
click to edit
![]()
