AUTHORIZATION TO RELEASE
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| Instructions: Please print this page and fill in the blanks as indicated. Bring the completed page to Campus Billing Services, 109 Aldrich Hall (Building 111). Office hours are Monday - Friday, 8:30 a.m. - 4:30 p.m. PT. Be prepared to show valid picture identification (e.g., UCI student ID, driver's license). Use your browser's Back function to return to the previous page. |
The privacy of personal information of a student, 18 years of age or older, or a student under age 18 attending a post-secondary education institution, is protected under FERPA (Federal Family Educational Right to Privacy Act of 1974) and the State of California Education Code. Without the express written permission of the student to disclose it, financial information is held in strict confidence and made available only to the student.
A student may wish to allow his financial information to be discussed with another individual, (a parent for example). The student must name the individual(s) and the relationship between them, and personally sign and deliver the release information. Campus Billing Services, the Central Cashier and Accounting will disclose financial information to the named individual(s) until this authorization is rescinded.
| (Please Print) | **Required Field | ||
| _____________________ | ___________________ | _________________ | ____________________ |
| Student Last Name, | First Name | Middle Name | **Student ID number |
| **Alternate ID | |||
| (Social Security, Driver's License, or Date of Birth) | ______________________________________ | ||
I hereby authorize Accounting and Fiscal Services to release my financial information to the following individual(s). The information may include all debits (charges), credits (payments, waivers) or holds on my UCI accounts.
| ______________________________________________________________________________ |
| Name |
| ______________________________________________________________________________ |
| Relationship |
| ______________________________________________________________________________ |
| Name |
| ______________________________________________________________________________ |
| Relationship |
| ______________________________________________________________________________ |
| Name |
| ______________________________________________________________________________ |
| Relationship |
I understand that I can revoke this authorization for any or all of these named individual(s) at any time, in writing.
| __________________________________________________ | ___________________________ |
| **Student Signature | **Date |