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Elem. Title VI ED 506 P. 15/19

OMB Number: 1810-0021 Expiration Date 02/29/2020

U.S. Department of Education

Office of Indian Education

Washington, DC 20202

Title VI ED 506 Indian Student Eligibility Certification Form

Parent/Guardian: This form serves as the official record of the eligibilitydetermination for each individual child included in the student count.  You are not required to complete or submit this form.  However, if you choose not to submit a form, your child cannot be counted for funding under the program.  This form should be kept on file and will not need to be completed every year.  Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Educational Rights and Privacy Act, 20 U.S.C. 1232g, andany applicable state of local confidentiality requirements.

Student Information

Tribal Enrollment

The individual with the tribal membership is the:*
Answer Required
The Tribe or Band is (select only one):*
Answer Required
Proof of enrollment in tribe or band listed above, as defined by tribe or band is either/or:*
Answer Required

Name and address of tribe or band maintaining enrollment data for the individual listed above:

Address
State
Answer Required

Attestation Statement

I verify that the information provided above is accurate.

Address
State
Answer Required

Pressing the submit button is the same as signing this form

Confirmation Email