To: [Name of designated official]
From: _______________________ [Name, title, organization]
I hereby request permission to examine the following part(s):
of the official education records of: ____________________ [name of student(s)] at: ___________________ [name of agency or school]. I certify that I am (check one as appropriate):
______ An authorized official of another school system in which the student intends to enroll.
______ An authorized representative of the Comptroller General of the United States.
______ An authorized official of the financial institution to which the student applied to receive financial aid. The purpose of this request is to determine eligibility, amount of aid, conditions of aid award, and enforcement of award terms and conditions.
______ An authorized official of an accrediting organization. I understand that release is allowed on the conditions that only appropriate members of my organization view the records and that resulting studies do not identify any particular student.
______ An authorized representative of the Secretary of the U.S. Department of Education.
[Add other categories as allowed in state or local laws and regulations.]
I agree that no unauthorized person or organization will have access to any records or information obtained through this request without the written permission of the parents of the student or the student. I understand the maximum penalties for redisclosure of the record will be [as set forth by federal and state laws and regulations].
Signature: ____________________ Date: ____________________
For Official Use Only:
Request approved/denied by: ______________________________