DEFERRED ACTION REQUEST

Relationship to Student* -Self -Parent/Legal Guardian

1. NAME (Current):

Last: *		First: *
Middle:

2. Name Used in School (if different from Current Name)*

Last:		First:
Middle:

* If you have changed your name since attending an LAUSD school, please provide a copy of the legal document(s) showing both your former name and new name. Your request will not be processed without this required documentation. A legal document may be a copy of Marriage Certificate, Naturalization Certificate (copy of both sides) or Court document indicating the name change.

3. Mailing Address:

Number, Street, and Apt#: *		City: *
State: *		Zip: *

4. Telephone Number:

Home Phone: *		Work Phone:
Cell Phone:

5. Date of Birth (MM/DD/YYYY):*

6. Gender:*

Male Female

7. Email Address:*

Email:
Confirm Email:

8. Year Graduated or last Year Attended (YYYY):

9. Name of LAUSD School last Attended:*

10. Authorization for Release* The signature below authorizes the release of my student records and confirms I have completed all sections accurately and truthfully, including information verifying my identity. I understand that an incomplete form will not be processed.

	Type in Name
Signature of Parent/Guardian (if student is under 18)		Date
Signature of Student (if student is 18 or older)		Date

* are mandatory fields.

Method of NotificationAll requests will be mailed via U.S. mail. To check the status of your request, please go to http://DACArequest.lausd.net

I declare under penalty of perjury that the foregoing is true and correct. *

Verify

Retype the number showing in the box above: *

Digital Signature (please type your name): *

Note: Your request will be researched and if it is available, you will receive an email notification requesting for payment through PayPal or money order. Please check your e-mail for future notifications. There is a $5 fee per copy.

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