Independent Status Request

I, ______________________________________________,
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: ___________________

*Declaration of independence on this form is for purposes of restricting access to your education records only and has no bearing on your status for purposes of applying for or receiving financial assistance through Brandeis University.