AUTHORIZATION TO RELEASE INFORMATION- FERPA/ 1098-T ACKNOWLEDGMENT FORM

AUTHORIZATION TO RELEASE INFORMATION- FERPA/ 1098-T ACKNOWLEDGMENT FORM
General Information
University of the Potomac ensures confidentiality of student records in accordance with the Family Educational Rights and Privacy Act (FERPA), as outlined in the University Catalog. Therefore, the University will not share academic and/or enrollment information (except for directory information shared INTERNALLY) with anyone unless you specifically designate them as someone authorized to obtain this information. Exceptions include Law Enforcement with proper identification.
STUDENT INFORMATION
Printed Name:*

First NameMiddle NameLast Name
Student ID #
If not known, add 000000000
Date of Birth*

MonthDayYear
Date
Social Security Number*
If you don't have 000-00-0000
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Would you like to release your educational records to someone?

YESNO
AUTHORIZATION: I, *
hereby authorize University of the Potomac to provide the following individual with copies of educational related documents as listed below. I acknowledge that I understand the purpose of the request and that authorization is hereby granted voluntarily:
Name of individual:*

First NameMiddle NameLast Name
Address of individual:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email of individual:*
example@example.com
Phone*
Please enter a valid phone number.
Relationship with the student:*
Information or Documents Authorized for Release:

Student academic reportStudent enrollment statusOther (Please explain in detail.)
By signing below, I consent to the release of the above listed information and/or documents to the above-mentioned individual. I understand that the authorization to release information must be updated as information changes. I understand I must submit one request per individual.
By checking this box and signing below, I agree to receive only an electronic, printable version of my 1098Tform. I understand that the 1098T form is accessible from the Student Portal or Alumni Portal.
I acknowledge that the information I have provided here is correct.*

Clear
Student Signature
MonthDayYear
Date
Office Use Only
Received by:

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: