University Cash Services Authorization to Release Financial Information

UNIVERSITY CASH SERVICES TEL NO: (818) 677-2318 FAX NO: (818) 677-4911 MAIL DROP: 8214

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The Family Educational Rights and Privacy Act (FERPA) of 1974 is designed to protect the privacy of a student's educational records. These confidential records include financial aid, scholarship and billing/account information, and will not be released without written consent from the student.

By signing this form, I authorize Financial Services to discuss confidential account information for the purposes of understanding and meeting University related financial obligations with the person(s) listed on this form. I understand that the person(s) listed on this form will have access via telephone, fax, or by U.S. and electronic mail to information that may include the following:

• My student account, including payments and charges posted to that account, financial aid balance checks, and any refund amounts I may have received. • My financial aid and scholarship award types and amounts. • My housing and meal plan charges, which may include amounts owed as well as amounts paid. • Any other unpaid bills that are owed to the University.

I. RELEASE INFORMATION TO THE FOLLOWING PERSON:
Name:	Relationship to Student:
Address:

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This authorization will remain in effect until revoked in writing by the student or until the end of the academic year in which it was issued. Forms should be submitted in person to University Cash Services, Bayramian Hall. Picture identification required.

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II. STUDENT SIGNATURES:
Student Name:	ID#:
Student Signature: _____________________________	Date: __________
Verified By (UCS Staff Name): _____________________	Date: __________
Forms not submitted to University Cash Services in person, must be originals, notarized, and mailed to:
University Cash Services 18111 Nordhoff Street Northridge, CA 91330-8214

NOTARY INFORMATION:	PLACE NOTARY STAMP HERE:
STATE OF: _____________________________ COUNTY OF: ____________________
DATE: ___________________ COMISSION EXPIRES: _________________________
SIGNATURE OF NOTARY PUBLIC:
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