Accounting Release of Information by kxy29287

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									                           MARICOPA COUNTY COMMUNITY COLLEGE DISTRICT
                                 2411 West 14th Street, Tempe, AZ                     85281-6942

                        AUTHORIZATION TO RELEASE EDUCATION RECORD
                                                             Financial
The purpose of the Educational Rights and Privacy Act of 1974 is to protect the privacy of information concerning
individual students by placing certain restrictions on the disclosure of information contained in a student’s university
records. I understand that in order for the College Accounting Office to honor a verbal or written request for
information by anyone other than the individual student, a signed and notarized authorization must be on file.

Name of Student: ________________________________________                Student I.D. #: _______________________

College: _____________________________________________________________________________________

I, the undersigned, hereby authorize the College Accounting Office to release information to:

_____________________________________________, _______________________________________________.
                        (NAME)                                           (RELATIONSHIP TO STUDENT)

                          PLEASE INCLUDE BOTH MOTHER AND FATHER’S FIRST NAMES

I understand that this pertains to information regarding ALL of the following: ACCOUNTS RECEIVABLE
(itemized charges and credits); FINANCIAL AID (itemized charges, credits, and refunds); HOUSING (charges,
credits, and itemized damage charges); REGISTRATION (number of credit hours, hours added, and hours dropped);
TELEPHONE (summarized charges and credits – Telecommunications Office can be contacted for detailed
information).

I would / would not (please circle one) like my monthly accounting statements to be sent to my home address
below. I understand that this mail request applies ONLY to my monthly receivable accounting statements and
tuition and fee bills. I also understand that it is my responsibility to modify this form if my address should change.

The above information will be released with my FULL CONSENT. I understand that this authorization remains in
effect from today through _______________________ (Month/Year). I understand further that (1) I have the right
not to consent to the release of my education records; (2) I have the right to receive a copy of such records upon
request; (3) and that this consent shall remain in effect until revoked by me, in writing, and delivered to MCCCD,
but that any such revocation shall not affect disclosures previously made by MCCCD prior to the receipt of any such
written revocation.

Signature: _____________________________________                Address: __________________________________

Name: ________________________________________                            __________________________________

Date: _________________________________________                 Phone No.: ________________________________

STATE OF ARIZONA                    )
                                    ) ss.
COUNTY OF _________________________ )

Subscribed and sworn to before me by _________________________ this ____ day of ________________, 20___.

Notary Public: _____________________________________ My Commission Expires: ____________________

THIS INFORMATION IS RELEASED SUBJECT TO THE CONFIDENTIALITY PROVISIONS OF
APPROPRIATE STATE AND FEDERAL LAWS AND REGULATIONS WHICH PROHIBIT ANY FURTHER
DISCLOSURE OF THIS INFORMATION WITHOUT THE SPECIFIC WRITTEN CONSENT OF THE PERSON
TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS.


MC-ATRER-F (07/20/05)
ED BY SUCH REGULATIONS.


MC-A TRER-F (07/20/05)

								
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