Authorization for Third Party Payment Web Form

A PDF version of this form is available for printing and faxing.

Submitting data using this web form will send the data to the departmental e-mail mailbox of the Enrollment Center at Inver Hills Community College. If the process worked correctly you will receive a confirmation page.

For information or questions, please e-mail enrollment@inverhills.edu or call 651-450-3752 and ask to speak with the person handling 3rd party payment.

Fields marked with an asterisk "*" are required.

Student Information
Student Name:*
Student ID Number:* (IHCC Student ID number preferred Will accept Social Security Number)

Funding Organization / Agency Information
Customer ID Number:* (found on upper left hand corner of invoice)
Organization:
Contact Name:*
Billing Street Address:*
Billing City, State, and Zip code:*	,
Contact Phone Number:*
Contact E-Mail Address:*
Sales Tax Exemption Number (if applicable):
Federal ID Number (if applicable):
Name of Authorizing Person:*

Funding Information
Should student grants be applied PRIOR to your agency funding?	Yes No
Term covered by funding:*

If your organization will pay 100% of some expenses, check the appropriate boxes to indicate which expenses will be covered 100%. Otherwise, specify a maximum dollar amount for each category expenses will be covered.
		100% of these expenses		Up to this amount for these expenses
Tuition & Fees			or	$
School Supplies			or	$
Required Books & Materials			or	$
Continuing Education			or	$
Other (specify)			or	$

Read the following data privacy information and click the submit button to send the data.

DATA PRIVACY NOTICE: Inver Hills Community College is asking you to provide information that includes private and/or confidential information under state and federal law. The college is asking for this information in order to process your third party funding authorization.

You are not legally required to provide the information the college is requesting; however, without the information the college will not be able to process your funding authorization. With some exceptions, unless you consent to further release of private information, access to this information will be limited to business office officials. Under certain circumstances, federal and state laws authorize the release of private information without your consent. Those conditions include releasing private information:

• to federal, state and local officials for purposes of program compliance, audit or evaluation;
• to your parents, if your parents claim you as a dependent student for tax purposes;
• if the information is sought with a subpoena, court order, or otherwise permitted by other state or federal law, and
• to an organization engaged in educational research or accrediting agency.

Inver Hills Community College abides by the provision of Title IX and other federal and state laws forbidding discrimination on the bases of sex, race, color, national origin or disability and all other state and federal laws regarding equal opportunity.