Form 506 - Title Vii Student Eligibility Certification printable pdf download

TITLE VII STUDENT

ELIGIBILITY CERTIFICATION

U.S. DEPARTMENT OF EDUCATION OFFICE OF INDIAN EDUCATION

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

Recognized

#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

Form 506 - Title Vii Student Eligibility Certification