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.
 

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(Signature)

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(Please Print Name)

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(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.
 

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NOtary Public

My Commission Expires: ___________________