Form 506 - Title Vii Student Eligibility Certification


Parents: Please return this completed form to your child’s school. In order to apply for a formula grant under
the Indian Education Program, your child’s school must determine the number of Indian children enrolled. Any
child who meets the following definition may be counted for this purpose. You are not required to complete or
submit this form to the school. However, if you choose not to submit a form, the school cannot count your child
for funding under the program. This form will become part of your child’s school record and will not need
to be completed every year. This form will be maintained at the school and information on the form will not be
released without your written approval.
Definition: Indian means any individual who is (1) a member (as defined by the Indian tribe or band) of
an Indian tribe or band, including those Indian tribe or bands terminated since 1940, and those recognized
by the State in which the tribe or band reside; or (2) a descendent in the first or second degree (parent or
grandparent) as described in (1); or (3) considered by the Secretary of the Interior to be an Indian for any
purpose; or (4) an Eskimo or Aleut or other Alaska Native; or (5) a member of an organized Indian group
that received a grant under the Indian Education Act of 1988 as it was in effect October 19, 1994.
NAME OF CHILD ___________________________________________ Date of Birth _______________
(As shown on school enrollment records)
School Name _________________________________________________ Grade ____________________
NAME OF TRIBE, BAND OR GROUP ______________________________________________________
Tribe, Band or Group is: (check one)
 Federally Recognized,
 State
 Terminated
 Organized Indian Group Meeting
Including Alaska Native
#5 of the Definition Above
Name of individual with tribal membership: ____________________________________________________
Individual named is (check one): _____ Child _____ Child’s Parent _____ Child’s Grandparent
Proof of membership, as defined by tribe, band, or group is:
A. Membership or enrollment number (if readily available) _____________________________________ OR
Other (explain) ___________________________________________________________________________
Name and address of organization maintaining membership data for the tribe, band or group:
I verify that the information provided above is accurate:
PARENT’S SIGNATURE _______________________________________ DATE ____________________
Mailing Address _______________________________________________ Telephone __________________
Parent’s Email address___________________________________________
Notice: Public Reporting Burden Notice on Reverse Side
Form #506
Please complete form and return to your student’s school.
OMB Number: 1810-0021
Expiration Date: 05/03/2016


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