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 STUDENT ELIGIBILITY CERTIFICATION FORM

Parent/Guardian: This form serves as the official record of the eligibility determination 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. ยง 1232g, and any applicable state or local confidentiality requirements.

STUDENT INFORMATION

As shown on school enrollment records​

TRIBAL ENROLLMENT

Individual named must be a descendent in the first or second generation​
Terminated tribe documentation​
Max file size: 10 MB

Proof of enrollment in tribe or ban listed above, as defined by tribe or band is:

OR

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

ATTESTATION STATEMENT

I verify that the information provided above is accurate.

Please provide an email address where we can send a link to your current form.

Email Address :