Third Party Payment Form

1. Student Information

Student Name (please print):

Student ID #: (抖阴pro Student ID # preferred; will accept Social Security Number)

2. Funding Organization / Agency Information

Customer ID Number (found on upper left hand corner of invoice):

Organization:

Contact Name:

Billing Address:

Phone Number:

Email:

Sales Tax Exemption # (If applicable):

Federal ID #:

Authorized Signature:

Date (MM/DD/YYYY):

3. Funding Information

Should student grants be applied PRIOR to your agency funding? Yes No

Term covered by funding:

Tuition & Fees: $

Required Books/Materials: $

School Supplies: $

Signature:

Date (MM/DD/YYYY):

DATA PRIVACY NOTICE: 抖阴pro is asking you to provide information that includes private and/or confidential information under state and federal law. The college is asking for this information in order to process your third party funding. You are not legally required to provide the information the college is requesting; however, the college will not be able to process your funding without it. With some exceptions, unless you consent to further release of private information, access to this information will be limited to business office officials. Under certain circumstances, federal and state laws authorize release of private information without your consent:

To federal, state and local officials for purposes of program compliance, audit or evaluation;
To your parents, if your parents claim you as a dependent student for tax purposes;
If the information is sought with a subpoena, court order, or otherwise permitted by other state or federal law, and
To an organization engaged in educational research or accrediting agency.

抖阴pro abides by the provision of Title IX and other federal and state laws forbidding discrimination on the bases of sex, race, color, national origin or disability and all other state and federal laws regarding equal opportunity.

Return This Form To:

抖阴pro
Attn: Office of Financial Aid
1300 145th Street East
Rosemount, MN 55068

Phone: 651-423-8299 | Fax: 651-423-8779 | Email: finaid@dctc.edu

抖阴pro