Form Fa-075 - Verification Of School Attendance
Download a blank fillable Form Fa-075 - Verification Of School Attendance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fa-075 - Verification Of School Attendance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3ARIZONA DEPARTMENT OF ECONOMIC SECURITY
FA-075-FF (8-17)
Page 1 of 3
Family Assistance Administration
VERIFICATION OF SCHOOL ATTENDANCE
VERIFICACION DE ASISTENCIA ESCOLAR
DATE
CASE NUMBER
•
•
CASE NAME (Last, First, M.I.)
EI’S NAME
EI’S PHONE NUMBER
•
•
TO THE SCHOOL ADMINISTRATOR: The person whose signature appears below has requested your cooperation in releasing the following
information. Please complete and return this form WITHIN 10 DAYS from the above date, to the Department of Economic Security.
AUTHORIZATION TO RELEASE INFORMATION / Autorización para dar información
I, as parent or caretaker relative of the child(ren) listed below, authorize the release of the requested information to the Department of Economic
Security. Yo, padre/madre/pariente a cargo del niño(s) nombrado a continuación, autorizo a que se dé la información solicitada al Departamento
de Seguro Económico.
NAME OF PARENT/CARETAKER RELATIVE (Last, First, M.I.) /
NOMBRE DE PADRE/MADRE/PARIENTE A CARGO (Apellido, Nombre, S.I.)
SIGNATURE OF PARENT/CARETAKER /
DATE /
FIRMA DE PADRE/MADRE/PARIENTE A CARGO
FECHA
ADDRESS (No., Street, Space or Apartment No.) /
DOMICILIO (Núm., calle, núm. de apto. o espacio)
CITY / CIUDAD
STATE / ESTADO
ZIP CODE / CÓDIGO POSTAL
SCHOOL ATTENDANCE FOR LAST
SCHOOL ATTENDANCE
FULL SCHOOL QUARTER
Is there Good
Attendance
NAME OF CHILD(REN)
STUDENT’S
DATE
DATE
Cause for the Child
Equals 90%
to Attend School
(Last, First, Middle)
BIRTHDATE
ENTERED
WITHDRAWN
or More
less than 90%
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1. Address shown on records for the child(ren):
2. Is the name of the parent/caretaker relative on the school record different from above?
Yes
No
If yes, it is
3. Is the address of the parent/caretaker relative on the school record different from above?
Yes
No
If yes, it is
4. Is the address of the child(ren) on the school record different from that of the parent/caretaker relative above?
Yes
No
If yes, it is
5. Is there a student in the 12th grade?
Yes
No
If yes, the date of the student’s last scheduled class is
Graduation Date:
6. If the student attends boarding school, do they return home on weekends or holidays?
Yes
No
•
•
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
RETURN TO
•
•
See page 3 for USDA/EOE/ADA/LEP/GINA disclosures
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form 08-4113a - Verification Of Licensure Form - Board Of Psychologist And Psychological Saaociate Examiners
Legal
Form Bia-4432 - Verification Of Indian Preference For Employment In The Bureau Of Indian Affairs And The Indian Health Service
Legal
Related Categories
Parent category: Legal