Third Party Authorization for Payment

Hennepin Technical College Authorization for Payment

A member of Minnesota State Colleges
and Universities

Hennepin Technical College
Attn: Third Party Billing
9000 Brooklyn Blvd. Brooklyn Park, MN 55445
Phone (763) 488-2517 - Fax (763) 488-2952
jena.gray@hennepintech.edu

1. Student Information

Student Name: _____________________________ Student ID Number: _______________________
(HTC Student ID # preferred; will accept Social Security Number)

Student Address: ______________ City: ________________ State: ______ ZIP Code: ___________

2. Funding Organization / Agency Funding

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

Organization: ____________________________________________________________________

Contact Name: ______________________________________ Phone Number: ______________

Billing Address: _______________________________________

________________________________

________________________________________

Fax Number: ___________________________ E-Mail: ___________________________________

Sales Tax Exemption #: _______________________ Federal ID #: ___________________
(If applicable) (If applicable)

Authorized Signature: ________________________________________ Date: ______________________

3. Funding Information

Should student grants be applied PRIOR to your agency funding? (circle one)

YES NO

Term covered by funding:
_______________________________

Your funding expires:
_______________________________

If authorizing 100%, please check appropriate box:	Or:	Specify dollar amount below:
Application Fee		$ ____________
Tuition and Fees		$ ____________
Books		$ ____________
Supplies		$ ____________
Continuing Education		$ ____________
Other: ______________		$ ____________

4. Student Release

I, the undersigned, hereby authorize Hennepin Technical College to disclose any necessary educational data/information related to receiving funding from the above agency/organization. I understand that the records information related to receiving funding may contain data that is classified as private under the Minnesota Data Practices Act, Chapter 13 and/or the Federal Family Education Rights and Privacy Act. I understand by signing the Informed Consent Form that I am authorizing Hennepin Technical College to release or receive information that would otherwise be private and not accessible to them. I understand that without my consent, such information could not be released. This consent expires upon completion of agency funding, or after one year, whichever comes first. I am giving this consent freely and voluntarily, and I understand the consequences of giving my consent.

Student Signature: _________________________________ Date: _________________________

DATA PRIVACY NOTICE: Hennepin Technical College 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. 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.

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

HTC is an affirmative action equal opportunity educator and employer.
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