North Dakota State College of Science • 800 Sixth Street North • Wahpeton, ND 58076-0002 • 1.800.342.4325 • www.NDSCS.edu
Haverty Hall 139 | 701.671.2216 | NDSCS.BusinessAffairsO
THIRD PARTY or EMPLOYEE Consent to Release Financial Student Records
to EMPLOYER for Billing Purposes
(Family Educational Rights and Privacy Act – FERPA)
According to the Family Education Rights and Privacy Act of 1974 (FERPA), a student’s academic and nancial
information may only be released to the student. However, students may elect to share their nancial and/or academic
records to outside parties via a FERPA consent form. The below FERPA consent applies to the Employee/Employer
relationship for the purpose of billing the Third Party or Employer for pre-approved charges incurred by their Employee, an
NDSCS student.
To Be Completed By Student/Employee
Third Party/Employer ______________________________________________________________________________
Name and Title of Third Party/Employer’s Representatives(s) Authorized to Receive Billing Information
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Student/Employee Name ___________________________________________________________________________
NDSCS Student ID_________________ Today’s Date_________________ Program __________________________
Student/Employee is authorizing NDSCS to release nancial account information to the Third Party/Employer for the
following semesters ______________________________________ to _____________________________________ .
(month/year) (month/year)
Student/Employee Acknowledgement
Initial each statement
_____ I understand that this consent serves as my request for NDSCS to establish a relationship with my Third Party/
Employer. This relationship will result in the Third Party/Employer becoming aware of the items charged to my
NDSCS student account and my balance owed to NDSCS.
_____ I understand that I will be responsible for notifying my Third Party/Employer if I am no longer enrolled at NDSCS.
_____ I understand that this consent is temporary and applies only to the semesters listed above.
_____ I understand that if my Third Party/Employer does not make payment by the due date, I may become nancially
responsible for the charges owed. Also, my account may be subject to late fees, future semester registration
delays, and transcript holds.
By signing this form, I authorize NDSCS to share my nancial records with the individual(s) listed above. I acknowledge
that, although I am not required to release my records to these individuals, I understand that: 1) I have the right not to
consent to the release of my education records; 2) I have a right to receive a copy of such records, upon request; and
3) This temporary consent expires at the end of the semesters listed above, but that such expiration shall not affect
disclosures made by NDSCS prior to the expiration.
Student/Employee Signature__________________________________________ Date _________________________
This information is released subject to the condentially provisions of appropriate state and federal laws and regulations
which prohibit any further disclosure of this information without the specic written consent of the person to whom it
pertains, or as otherwise permitted by such regulations.
Questions? Contact Nicole - 701-671-2135 | Nicole.Matejcek@ndscs.edu
Return Completed Forms To:
NDSCS Business Affairs, 800 6th St. N., Wahpeton, ND 58076 | NDSCS.BusinessAffairsOfce@ndscs.edu
click to sign
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