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Forum Guide to Protecting the Privacy of Student Information: State and Local Education Agencies

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Exhibit 65: Sample Statement of Nonrelease of Released Information

I understand that upon receipt of the information provided by [name of agency or school] regarding [type of information] about [name of student(s)], the re-release of such information is prohibited by the Family Educational Rights and Privacy Act of 1974, as amended [and cite state and local laws, where applicable]. I acknowledge that I fully understand that the intentional release by me of this information to any unauthorized person could subject me to [criminal and civil penalties, where applicable] imposed by law.

Signature: _________________________________

Name: _________________________________

Title: _________________________________

Organization: _________________________________

Date: _________________________________

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