LOS ANGELES UNIFIED SCHOOL DISTRICT
STUDENT RECORDS AND DATA MANAGEMENT BRANCH
DEFERRED ACTION REQUEST FORM

Relationship to Student*          

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):*
    
Applicants must be at least 15 years old (born between 1981 and 2002) unless the minor is currently in removal proceedings or has a final removal order or voluntary departure order and is not in immigration detention.

6. Gender:*
         

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

  *    

   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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