Inver Hills Community College Authorization for Payment
Inver Hills Community College
Attn: Third Party Billing
2500 E. 80
th St., Inver Grove Heights, MN 55076
Phone: (651) 450-3927 Fax: (651) 450-3677
Signature Date
DATA PRIVACY NOTICE: Inver Hills Community College is asking you to provide information that includes private and/or confidential information
under state and federal law. The college is asking for this information in order to process your third party funding.
You are not legally required to provide the information the college is requesting; however, the college will not be able to process your funding
without it. With some exceptions, unless you consent to further release of private information, access to this information will be limited to business
office officials. Under certain circumstances, federal and state laws authorize release of private information without your consent:
To federal, state and local officials for purposes of program compliance, audit or evaluation;
To your parents, if your parents claim you as a dependent student for tax purposes;
If the information is sought with a subpoena, court order, or otherwise permitted by other state or federal law, and
To an organization engaged in educational research or accrediting agency.
Inver Hills Community College abides by the provision of Title IX and other federal and state laws forbidding discrimination on the bases of sex, race,
color, national origin or disability and all other state and federal laws regarding equal opportunity.
1. Student Information
Student Name: Student ID Number:
(IHCC Student ID # preferred; will accept Social Security Number)
2. Funding Organization / Agency Information
Customer ID Number (found on upper left hand corner of invoice):
Organization:
Contact Name:
Billing Address:
Phone Number: Email:
Sales Tax Exemption #: Federal ID #:
(If applicable)
Authorized Signature: Date:
3. Funding Information
Should student grants be applied
PRIOR to your agency funding?
YES
NO
Term covered by funding:
Tuition & Fees $
Required Books/Materials $
School Supplies $
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