Rev 1.0(12.07.2007)
RELEASE OF INFORMATION
Office of the Controller
Student Name: _____________________________ UWG ID/SSN: ______________________
(SSN required for tax or Perkins loan information)
I request the Controller’s Office at UWG release the requested information to the party below:
Name: ____________________________________ Relationship to student: Parent
Guardian Spouse
Other: _________________________
Address: __________________________________ Phone: _____________________
___________________________________
___________________________________
Purpose of Request:
Issue involving payment of tuition, fees or related charges. (Current Term students)
Issue involving collection of student account (Prior Term students)
Tax information
Other: ____________________________________________________________________________
Information Requested: (Please check all that apply)
Student Account Information (may include payments, charges, refunds and 1098t information).
Note: SSN is required if tax information is needed/requested.
Information required to re-issue a lost/damaged check (may include but not limited to address
information and check amount). Written authorization for requesting a check be re-issued
must be submitted by the student.
Repayment Information: (Please check all that apply)
Short Term Loan Information (may include but not limited to past-due/default status, principal,
interest, late fees and collection amounts and information, address information, copies of
promissory notes and due-diligence information).
Perkins Loan Information (SSN # required at the top – may include but not limited to past-
due/default status, principal, interest, late fees and collection amounts and information, address
information, copies of promissory notes and due diligence information).
Returned Check Information (may include but not limited to amount and penalties).
I hereby grant the Controller’s Office permission to speak/send information to the above listed party at the
address listed.
________________________________ __________________
Student Signature Date
________________________________ __________________
Witness (Controller Staff) Date
To be completed by Witness
Type of ID:
Student ID Drivers License: ___________(ST) Other: _________________________
