DEPARTMENT OF HUMAN RESOURCES

FAMILY INVESTMENT ADMINISTRATION

Department of Social Services

SCHOOL VERIFICATION FOR ELEMENTARY & HIGH SCHOOL – ONLY

SECTION I: TO BE COMPLETED BY FI WORKER

Control # District Office:

Worker’s Name: Category and Case#:

Worker’s Phone:__________________________________ Case Name:

Please provide the information requested below about who is a

student at your school. The information will be used to determine his/her eligibility for one of our programs.
Consent to release this information is provided in Section II below.

SECTION II: TO BE COMPLETED BY PARENT FOR MINOR CHILD OR STUDENT FOR HIMSELF IF
OVER 18

, hereby authorize
Name of School

to release to the Department of Social Services information concerning school enrollment, for the purpose of
redetermining eligibility.

Signature Date

SECTION III: TO BE COMPLETED BY SCHOOL

A. Type of Enrollment:
1 Secondary School (public or private) 1Vocational School 1Technical School
B. Is the student full-time 1Yes 1No
C. Expected date of graduation:
Date (Month & Year)

D. Attendance record:
1Regularly attends, except for occasional sickness
1Not attending
E. Home address and telephone number of student:
Address (Number and Street):
City, State, and Zip Code:
Telephone Number:
F. Full names of all parents/legal guardians listed in student’s home:
1. Work Phone#:
2. Work Phone#:
G. Emergency phone numbers:

Name and Address of School Institution

(PLEASE USE SCHOOL STAMP)

DHR/FIA 604 (Revised 8/96) Previous editions are obsolete.