2017
--
2018
Request to Release
Personal and Confidential
Information
Student ID
_________________________________________________________ ________________________________ ______
Last Name
First
Name
M.I
The Office of Financial Aid at Pasadena City College (PCC) is required by the Family Educational Rights and Privacy Act
(FERPA), Title 34, Part 99, to release detailed information to the student only. However, by signing the statement below,
the student may voluntarily waive his/her privacy rights, thereby authorizing PCC to release the contents of personal and
confidential information to specific individual(s) or agencies. By completing this form, the named person(s) will be able
to obtain information regarding the student's financial aid status, PCC's cost of attendance and determination of
financial aid eligibility, and request to review the contents of the file. This statement does not authorize the release of
any documents in the student's file. The student must make a separate written request for copies of documents
contained in his/her file. In signing this request, the student understands that the waiver is valid for one (1) academic
year, and that a new waiver must be signed each subsequent academic year that the student is in attendance at PCC.
I,
hereby waive my rights under the Family Educational
Rights and Privacy Act (FERPA) by authorizing the Office of Financial Aid at PCC to share any requested information
concerning my financial aid application and/or award(s) information to:
Please Print the First and Last Name of the Person(s) or Name of Agency Authorized to Obtain your Financial Aid Information
Upon request, an
i
ndiv
i
dual may be asked to prov
i
de PCC with at
l
east one form of photo and
additional information to confirm your identity.
Student’s
Si
gnature Date____________________
This waiver does not provide to the person(s) listed above any or all information pertaining to the amount of the student's
financial aid disbursement(s). PCC reserves the right to withdraw the authorization if there are instances or c
i
rcumstances
of abuse or evidence of a conflict of interest.
(05/10 OSFA FERPA)
1570 East Colorado Blvd.L-114, Pasadena, California 91106
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2003
18FERP
