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Protecting the Privacy of Student Records
Exhibit 6-4
Sample Statement of Non-Disclosure
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 rerelease of which is prohibited by the Family Educational Rights and Privacy Act of 1974 [and cite state or 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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