Data Use Agreement Page 4

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5361, Page 4
Data Use Agreement
High School Principal
Data Receiver Point of Contact/Data Custodian
Complete, sign, and submit along with a completed Form 5360
High School Principal
Title
High School
Telephone Number
Address
E-mail Address
Signature
Date
The attached Data Receiver Designee form is to list a counselor(s) in your high school or Intermediate School
District (ISD) who will have access to MiSSG for the purpose of viewing student Free Application for Federal
Student Aid and Tuition Incentive Program (FASFA/TIP) data. The designee(s) must be an employee of your high
school or ISD and housed within your high school building.
The attached Secondary Security Access form is to list a partner(s) who has your approval to review the report with
your students.
Data Provider Point of Contact
Carla Foltyn
Director, Student Scholarships and Grants Division
Michigan Department of Treasury/Student Financial Services Bureau
1-888-447-2687
PO Box 30462
Lansing Michigan 48909-7962
Anne Wohlfert
Director, Student Financial Services Bureau
Michigan Department of Treasury/Student Financial Services Bureau
1-888-447-2687
PO Box 30462
Lansing Michigan 48909-7962
TREASURy USE Only
Data Provider Designated Signatory
Date

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