* Required

Title VI ED 506 Indian Student Eligibility Certification Form

Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student count. You are not required to complete or submit this form. However, if you choose not to submit a form, your child cannot be counted for funding under the program. This form should be kept on file and will not need to be completed every year. Where applicable, the information contained in this form may be released with your prior written consent or the prior written consent of an eligible student (aged 18 or over), or if otherwise authorized by law, if doing so would be permissible under the Family Education Rights and Privacy Act, 20 U.S.C. 1232g, and any applicable state or local confidentiality requirements.

Student Information
Tribal Membership
Proof of Membership: Membership may be established by including an enrollment number if available or by other evidence as appropriate
Please Describe and attach any supporting documents​
Max file size: 10 MBWord, PDF, or Image files only
Parent/Guardian Attestation Statement
By entering my name and today's date below, I verify that all the information provided above is accurate.

This form is a digital version of US Department of Education ED 506 Form with OMB Number: 1810-0021 Expiration Date: 02/29/2020

If you would prefer to complete a paper copy of this form, please click here to download. Paper forms may be scanned and Faxed to 503-356-3760, or mailed to:

ATTN: Title VI AI/AN Program

Multilingual Department

1260 NW Waterhouse Ave

Beaverton, OR 97006