Fillable Support-for-native-american-students-form Title VI ED 506 Student Eligibility Certification Form

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Support-for-native-american-students-form Title VI ED 506 Student Eligibility Certification Form

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OMB Number: 1810-0021
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 _______________
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OMB Number: 1810-0021 Expiration Date: 02/29/2020
INSTRUCTIONS FOR THE ED 506 FORM
FOR APPLICANTS:
PURPOSE: To comply with the requirements in 20 USC 7427(a), which provides that: “The Secretary shall require that, as part of an application for a
grant under this subpart, each applicant shall maintain a file, with respect to each Indian child for whom the local educational agency provides a free
public education, that contains a form that sets forth information establishing the status of the child as an Indian child eligible for assistance under
this subpart, and that otherwise meets the requirements of subsection (b)”.
MAINTENANCE: A separate ED 506 form is required for each Indian child that was enrolled during the count period. A new ED 506 form does NOT
have to be completed each year. All documentation must be maintained in a manner that allows the LEA to be able to discern, for any given year,
which students were enrolled in the LEA’s school(s) and counted during the count period indicated in the application.
FOR PARENTS/GUARDIANS:
DEFINITION: Indian means an individual who is (1) A member of an Indian tribe or band, as membership is defined by the Indian tribe or band,
including any tribe or band terminated since 1940, and any tribe or band recognized by the State in which the tribe or band resides; (2) A
descendant of a parent or grandparent who meets the requirements described in paragraph (1) of this definition; (3) Considered by the Secretary
of the Interior to be an Indian for any purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that
received a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.
STUDENT INFORMATION: Write the name of the child, date of birth and school name and grade level.
TRIBAL ENROLLMENT INFORMATION: Write the name of the individual with the tribal membership. Only one name is needed for this section, even
though multiple persons may have tribal membership. Select only one name: either the child, child’s parent or grandparent, for whom you can
provide membership information.
Write the name of the tribe or band of Indians to which the child claims membership. The name does not need to be the official name as it appears
exactly on the Department of Interior’s list of federally-recognized tribes, but the name must be recognizable and be of sufficient detail to permit
verification of the eligibility of the tribe. Check only one box indicated whether it is a Federally Recognized, State Recognized, Terminated Tribe or
Organized Indian Group. If Terminated Tribe or Organized Indian Group is elected, additional documentation is required and must be attached to
this form.
• Federally Recognized- an American Indian or Alaska Native tribal entity limited to those indigenous to the U.S. The Department of
Interior maintains a list of federally-recognized tribes, which OIE can provide you upon request.
• State Recognized- an American Indian or Alaska Native tribal entity that has recognized status by a State. The U.S. Department of
Education does not maintain a master list. It is recommended that you use official state websites only.
• Terminated Tribe-a tribal entity that once had a federally recognized status from the United States Department of Interior
and had that designation terminated.
• Organized Indian Group- 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.
Write the enrollment number establishing the membership of the child, if readily available, or other evidence of membership. If the child is not a
member of the tribe and the child’s eligibility is through a parent or grandparent, either write the enrollment number of the parent or grandparent,
or provide other proof of membership. Some examples of other proof of membership may include: affidavit from tribe, CDIB card or birth certificate.
Write the name and address of the organization that maintains updated and accurate membership data for such tribe or band of Indians.
ATTESTATION STATEMENT: Provide the name, address and email of the parent or guardian of the child. The signature of the parent or guardian of
the child verifies the accuracy of the information supplied.
The Department of Education will safeguard personal privacy in its collection, maintenance, use and dissemination of information about individuals
and make such information available to the individual in accordance with the requirements of the Privacy Act.
PAPERWORK BURDEN STATEMENT According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1810-0021.
The time required to complete this portion of the information collection per type of respondent is estimated to average: 15 minutes per Indian
student certification (ED 506) form; including the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your
individual submission of this form, write directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W.,
LBJ/Room 3W203, Washington, D.C. 20202-6335. OMB Number: 1810-0021 Expiration Date: 02/29/2020.
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Completed 3 July 2020

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