Authorization To Release Information Form

Financial Aid Authorization to Release Information Form

Online Submission

You must complete the Authorization to Release Information form if you wish to authorize the Office of Financial Aid to share your financial aid information with anyone other than yourself. For example, if you would like your parent(s), spouse, or anyone else to talk with Financial Aid staff about your aid, you must provide that information below. Failure to complete this form will not prevent the processing or payment of your financial aid; however, if this form is not on file in the Office of Financial Aid, staff will not discuss your financial aid record with anyone other than you, the student.

If you have any questions regarding this form, please contact the Office of Financial Aid at 717-871-5100, or via email.

Student Release Authorization Form

Authorization To Release Information Form

Authorization To Release Information Form

This is your form description. Click here to edit.

  • (without punctuation, e.g. 123456789 is correct; 123-45-6789 is NOT correct). If your ID begins with an M, enter an upper case M plus the remaining eight digits: e.g. M00012345

  • Student's Name Student's Name
  • Student's Date of Birth Student's Date of Birth / /
    Pick a date.

  • (optional: this will only be used to contact you if a problem or question arises)

  • Pursuant to the provisions of the Privacy Act of 1974 (5 USC 552a, PL 93-579, as amended), I hereby authorize the Offices of Financial Aid and the Bursar to release information from my financial aid record to the individuals listed below. I understand and agree that the information released will cover my entire academic career at Millersville University and I may change it at any time by completing a new Authorization to Release Information Form. I also understand that the released information may be electronically transferred by the Office of Financial Aid or its agents. In addition, I understand that the individual(s)/agency that I have designated below must verify my social security number and my date of birth before any information is released to them.
    Pursuant to the provisions of the Privacy Act of 1974 (5 USC 552a, PL 93-579, as amended), I hereby authorize the Offices of Financial Aid and the Bursar to release information from my financial aid record to the individuals listed below. I understand and agree that the information released will cover my entire academic career at Millersville University and I may change it at any time by completing a new Authorization to Release Information Form. I also understand that the released information may be electronically transferred by the Office of Financial Aid or its agents. In addition, I understand that the individual(s)/agency that I have designated below must verify my social security number and my date of birth before any information is released to them.

  • Individuals/Agencies to Receive Information

    All data related to a single individual/agency is required.

  • INDIVIDUALS:

  • Name Name
  • Name Name
  • Name Name
  • Name Name
  • Name Name

  • AGENCIES:

  • Phone Phone - -
  • Phone Phone - -