Student Name_______________________________________ SSN ______________________
                        (Please print)

I would like the information checked below released to:

Name: _______________________________________ Relationship _____________________

Please release information regarding my financial aid application including (check all you wish to release):

 _______ Documents received and needed

  _______ Income and FAFSA application data

 _______ Tax Information

 _______ Financial aid awarded funds

_______ Financial aid applied to the student’s account, used for books and/or refunded to the student

 _______ Other (specify) ____________________________________________________

This release is valid for the period 4/1/2010 to 8/30/2011for information pertaining to the 2010/2011academic year.  It may be canceled or changed at any time by notifying our office in writing.

Student signature _____________________________________ Date ____________________