92 Neb. Admin. Code, ch. 4, Appendix D - AUTHORIZED PARENT REPRESENTATIVE FORM

NDE # 22-004

Revised effective (date to be inserted later)

DATE DUE: 1/15

TO: ________________________________________________________________

(Board of education or school board of the school district in which the student requesting the loan resides or in which the private school the child attends is located.)

I,____________________________________, being a parent of a child

(please print)

enrolled in a private school which is approved for continued legal operation under Title 92, Nebraska Administrative Code (NAC), Chapter 14, or accredited under Title 92, NAC, Chapter 10, designate:

__________________________________________________________to be

(please print)

my Authorized Parent Representative to represent me in all the proceedings applicable to the Textbook Loan Program under Title 92, NAC, Chapter 4.

_______________ ________________________________

DATE PRINT NAME

______________________________

SIGN NAME

[] PARENT [] GUARDIAN

I understand that as an Authorized Parent Representative, I will represent the parent in all the proceedings applicable to Chapter 4, Textbook Loan Program, I am not an official or employee of a private school.

_______________ ________________________________

DATE PRINT NAME

______________________________

SIGN NAME

AUTHORIZED PARENT REPRESENTATIVE

Notes

92 Neb. Admin. Code, ch. 4, Appendix D