ETV Participant Release
&
Cashier Statement
I have applied for the federally-funded Education and Training Voucher (ETV) Program for the current quarter/semester to help meet my post-secondary expenses. This form must be completed by the cashier office.
STUDENT INFORMATION First Name: Student ID: Last Name: Phone:
I hereby authorize the release of information pertaining to my education/financial aid/grades to Department of Social and Health Services, Educational Training Voucher Program. Student Signature: Date:
CASHIER OFFICE A dated copy of the student’s itemized bill listing all charges, credits and payments for the current quarter/semester must be submitted with this completed form. School Name: Preparer:
Please Print
Phone: Date:
Signature:
By checking this box I certify I am authorized as an employee of the cashier/bursar office to complete this form
BALANCE DUE Current Balance Due: $ No balance Due
Date Due: By checking this box I certify that the balance noted takes into account both disbursed and anticipated federal financial aid.
PLEASE INDICATE TERM / QUARTER / SEMESTER
(If the balance due is for more than one quarter/semester please check all boxes that apply.)
Fall
Winter
Spring
Summer
This document must be faxed or mailed by the cashier office to:
ETV Program P.O. Box 45710 Olympia, WA, 98504-5710 FAX: 360-902-7588 Toll Free1-877-433-8388 Email: etvwash@dshs.wa.gov