Fill - Free fillable Parental-Verification-of-Dependency - Parental Verification of Dependency PDF form

TexasWoman’sUniversity

OfficeoftheRegistrar

TWUOfficeoftheRegistrarPOBox425559Denton,TX76204E‐mail:registrar@twu.eduFax:940‐898‐3097Phone:940‐898‐3036

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DocType:___FERPA______

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Description:_____/_______

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Forofficeuseonl

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ParentalVerificationofStudentDependency

Thisformmustbecompletedeachtimeinformationisrequested

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TO:___________________________________________________



(Printnameofuniversitydepartmentmaintainingrecord.)



FROM:__________________________________________ ____________________________



(Nameofparentorguardianrequestinginformation.)

_______________________________________________________________________



(Addressofparentorguardianrequestinginformation.)



TheFamilyEducationalRightsandPrivacyActof1974,20U.S.C.1232etseq.,allowsTexasWoman'sUniversityto

discloseinformationfromtheeducationalrecordsofadependentstudent,asdefinedinsection152oftheInternal

RevenueCodeof1986,tohisorherparents,withoutthestudent’sconsent.The

term“parent”includesanatural

parent,guardian,orindividualactingasaparentintheabsenceofanaturalparentorguardian.Theuniversitymay

discloseinformationaboutadependentstudentmeetstherequirementsasadependentfortaxpurposesandthe

universityisnotawareofacourtorder,

Statestatute,orlegallybindingdocumentrelatingtosuchmattersasdivorce,

separation,orcustodythatspecificallyrevokeorotherwiseabrogatetherightsoftheparent(s).Theparentmust

provideproofofdependencyintheformofacopyoftheirmostrecenttaxreturnandagovernmentissuedphotoID.

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I,_______________________________ __________,certifythatIamtheparent,guardianorindividualactingasa



(Printfullnameofparent.)

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parentof______________________________________,(__________________),astudentenrolledatTexasWoman’s

(Printfullnameofstudent.) (StudentIDNumber)

University.IfurthercertifythatIclaimedtheabove‐namedstudentasadependentonmyFederalIncomeTaxformfor

themostrecentpersonalincometax‐filingperiod;thatthestudentcurrentlyismydepende nt(asdefinedbysection152

oftheInternalRevenueCodeof1986);thatIhave

notbeenarrestedfordomesticorfamilyviolenceagainstthe

dependent‐student;andthatIamnotawareofanycourtorder,statelaw,orlegallybindingdocumentth atrevokesor

otherwiseabrogatesanyrightsImayhaveasaparent,guardian,orindividualservingasaguardiantothe

student.

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Iherebyrequestthefollowingdocumen t(s)/information)frommydependent‐student’seducationalrecords.(Please

specifythedocument(s)/informationrequested.Includethespecificsemesterifdoingsowillassistinlocatingthe

document(s)/information.):



READBEFORESIGNING:Statelawanduniversitypolicy,withlimitedexceptions,allowyoutobeinformedof

informationtheUniversitycollectsaboutyou,toreviewandobtaintheinformationonthisformandtocorrectany

informationyoubelieveisincorrect.Bycompletingandsigningthisform,youacknowledgeunderstanding

thatthe

informationcontainedinthisformandtheaccompanyingattachmentswillbe usedbyTexasWoman'sUniversityto

determineyoureligibilitytoreceiveinformationmadeconfidentialbyfederallawandthatthisformisagovernmental

record.Yourfurtheracknowledgethatyouunderstanditisacriminaloffenseunderthe

TexasPenalCodetoknowingl y

makeafalseentryinthisform;tomake,present,orusethisformwiththeknowledgeofitsfalsityandwithintentthatit

betakenasagenuinegovernmentalrecord;andtomake,present,orusethisformwithknowledgethattheinformation

providedbyyouisfalse.

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_____________________________________________________ ________________

(SignatureofRequestor‐Parent)(Date)

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