Ed 506 Title Vi Ed 506 Indian Student Eligibility Certification

OMB Control No. 1810-0021 (Exp. XX/XX/20XX)

ED 506 Form
Indian Student Eligibility Certification Form for Title VI Indian Education Formula Grant Program
Parent/Guardian: This form serves as the official record of the eligibility determination for each individual child included in the student
count for the Title VI Indian Education Formula Grant Program. If you choose to submit a form, your child could be counted for funding
under the program. The grantee receives the grant funds based on the number of eligible forms counted during the established count
period. You are not required to complete or submit this form unless you wish for your child(ren) to be included in the Indian student count.
This form should be kept on file with the grant applicant 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 Educational Rights and Privacy Act, 20 U.S.C. §
1232g, and any applicable state or local confidentiality requirements.

Student Information
Name of the Child ___________________________________ Date of Birth __________ Grade level _________
Name of School___________________________________ School District_______________________________
Tribal Membership
The individual with Tribal membership is the (select only one): ___child ___child's parent ___ child's grandparent
If the individual with Tribal membership is not the child listed above, name the individual (parent/grandparent) with
tribal membership: _________________________________
Name and address of Tribe or Band that maintains updated and accurate membership data for the individual listed
above:
Name _________________________________________ Address ______________________________________
City ______________________________ State ______ Zip Code __________
The Tribe or Band is (select only one):
 Federally Recognized Tribe
 State Recognized Tribe
 Terminated Tribe
 Alaska Native
 Member of an organized Indian group that received a grant under the Indian Education Act of
1988 as it was in effect October 19, 1994.
Proof of membership in Tribe or Band listed above, as defined by Tribe or Band is:
Membership or enrollment number establishing membership ___________________________ (if readily available) or
other evidence establishing membership in the Tribe listed above ________________________ (describe and attach).
Attestation Statement
I verify that the information provided above is true and correct to the best of my knowledge and belief.
Printed Name of Parent/Guardian _____________________________ Signature___________________________
Address _____________________________ City _______________________ State ______ Zip Code _________
Phone Number ___________________________ Email____________________________ Date _______________

OMB Control No. 1810-0021 (Exp. XX/XX/20XX)

For Parent/Guardians:
Definitions:
Indian means an individual who is (1) A member of an Indian Tribe or Band, as membership is defined by the
Indian Tribe or Band, including any Tribe or Band terminated since 1940, and any Tribe or Band recognized by the
State in which the Tribe or Band resides; (2) A descendant of a parent or grandparent who meets the requirements
described in paragraph (1) of this definition; (3) Considered by the Secretary of the Interior to be an Indian for any
purpose; (4) An Eskimo, Aleut, or other Alaska Native; or (5) A member of an organized Indian group that received
a grant under the Indian Education Act of 1988 as it was in effect on October 19, 1994.
Student Information: Write the name of the child, date of birth, grade level, name of school and school district.
Only name one child per form.
Tribal Membership: Write the name of the individual with the tribal membership, if it is not the child listed. Only
one name is needed for this section, even though multiple persons may have tribal membership. Select only one
identifier: the child, child’s parent or grandparent, for whom you can provide membership information.
Write the name and address of the organization that maintains updated and accurate membership data for such Tribe
or Band of Indians. The name does not need to be the official name as it appears exactly on the Department of
Interior’s list of federally recognized Tribes, but the name must be recognizable and be of sufficient detail to permit
verification of the eligibility of the Tribe. Check only one box indicated whether it is a Federally Recognized, State
Recognized, Terminated Tribe or Organized Indian Group. Write the enrollment number establishing the
membership for the child, parent or grandparent, if readily available, or other evidence of membership.
Attestation Statement: Provide the printed name of parent/guardian and signature, address, phone number and
email of the parent or guardian of the child. The signature of the parent or guardian of the child verifies the accuracy
of the information supplied.
Paperwork Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB
control number for this information collection is 1810-0021. The time required to complete this portion of the
information collection per type of respondent is estimated to average: 15 minutes per Indian student certification (ED
506) form; including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C.
20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write
directly to: Office of Indian Education, U.S. Department of Education, 400 Maryland Avenue, S.W., LBJ/Room
3W238, Washington, D.C. 20202-6335