Gems Access Request Form (Page 2 of 2) in pdf

FAFSA Completion Initiative

By signature of the Authorized Representative below, the ________________________High School agrees to abide

by the following conditions with respect to the data that will be shared as part of the Free Application for Federal

Student Aid (“FAFSA”) Completion Initiative:



The FAFSA Filing Status Information will only be used for purposes consistent with section 483(a)(3)(E)

of the Higher Education Act (20 U.S.C. 1090(a)(3)(E));



The High School will take appropriate steps to protect the confidentiality of the FAFSA Filing Status

Information through privacy, data security, and information safeguarding measures;



The High School will comply, as applicable, with the requirements of the Family Educational Rights and

Privacy Act (“FERPA”) (20 U.S.C. § 1232g and its regulations codified at 34 CFR part 99) in disclosing

any personally identifiable information from students’ education records to the Office of Public Instruction

(“OPI”) or its agents;



The FAFSA Filing Status Information will only be accessed by employees of the High School who need

such access in order to determine the completion status of a student’s FAFSA and to facilitate the provision

of assistance to such students in completing the FAFSA for purposes of the FAFSA Completion Initiative.



The High School will not re-disclose or share the FAFSA Filing Status information obtained from OPI in

personally identifiable form other than (1) to the FAFSA applicant and to the FAFSA applicant’s parents if

the applicant is under age 18, to the applicant if the applicant is age 18 or older or enrolled in a post-

secondary institution, or to any other party with the consent of the FAFSA applicant or the FAFSA

applicant’s parents if the FAFSA applicant is under the age of 18, or (2) if required to do so by law and if

such use is consistent with all applicable privacy laws, including the privacy provisions of section

483(a)(3)(E) of the Higher Education Act, 20 U.S.C. 1090(a)(3)(E) and FERPA (20 U.S.C. 1232g).



The High School will promptly report in writing any unauthorized use, disclosure, or re-disclosure of

FAFSA Filing Status Information to the Office of Public Instruction. The Office of Public Instruction will

report to Jamie Dushin, Montana University System, MGSLP, Accounting/Claims Manager, (406) 444-

0381.

Authorized Representative must sign below in order to process this form.

With my signature below, I certify the accuracy of the information submitted on this form.

______________________________________________

______________________

Signature of Authorized Representative

Date

Gems Access Request Form Page 2