Independent Status Request
hereby declare that I am independent* from my parents/father/mother. I understand that this declaration is used for the purposes of denying to my parents/father/mother access to my education records at Brandeis University. I further understand that in order to declare independence hereunder from my parents/father/mother, my parent/father/mother cannot have treated me as a dependent on their/his/her most recently filed income tax return.
Please Print Name
SID# Class Year
Commonwealth of Massachusetts
County of Middlesex
On this ____________ day of ____________, 20______
personally appeared before me _________________________,
who, under oath, subscribed his name to the foregoing statement.
My Commission Expires: ___________________