Account Holder and Student Information Update Form

Account holders must regularly verify/update contact information on file to ensure regular and timely communications from the department. This includes, but is not limited to, any changes made to the following:

  • Email address
  • Physical address
  • Phone number
  • School type (i.e., independent home school, private school)
  • LEA of residence
  • Change in legal status (i.e., conservatorship or Power of Attorney documentation)

If at any time the student and/or account holder information submitted in the IEA application and/or contract changes, the account holder must report the changes by submitting this form to the department within seven calendar days of the change being effective. Failure to provide this information to the department by the deadline will result in payment delays and/or suspension of the IEA account or removal of the student from the IEA Program.

Please Note: 

  • For any address changes, the following documentation must be submitted to the department with this form: 
    • Proof of residency showing the account holder's name and physical address (e.g., a copy of most recent utility bill, current rental agreement, current property tax bill, affidavit from landlord, or most recent mortgage statement); AND
    • a NEW W-9 form listing the account holder’s current name and physical address. The W-9 form is posted on the forms tab of the IEA Webpage.
    • If the legal name of the student and/or account holder has changed, a copy of the legal document approving the name change (e.g., marriage certificate) must also be submitted to the department with this form. 



Tennessee Department of Education
Individualized Education Account (IEA) Program
Andrew Johnson Tower, 9th Floor
710 James Robertson Parkway • Nashville, TN 37243
Tel: (615) 253-3781• Fax: (615) 741-6793

ED5504 RDA 11163

Student Information

Directions: Please provide the information in the fields below. 


 


Student Name*
If the legal name of the student has changed, please attach a copy of the legal document approving the name change.
No File Chosen
File uploads may not work on some mobile devices.
Did your home address change?*
Physical Street Address (P.O. boxes will not be accepted)
Did your phone number change?*
Proof of residency which lists the account holder's name and physical address must be attached. Examples include the following: copy of most recent utility bill, current rental agreement, current property tax bill, affidavit from landlord, or most recent mortgage statement.*
No File Chosen
File uploads may not work on some mobile devices.
Copy of W-9 with Updated Address*
No File Chosen
File uploads may not work on some mobile devices.
Find the form at https://www.irs.gov/pub/irs-pdf/fw9.pdf
Did the student's type of school change?*
If the student transferred to/from a private school participating in the IEA Program, please submit the Notice of School Transfer form.
Note: If a student is enrolled in a home-school umbrella program, the student is considered to be enrolled in a private school.

Account Holder Information

Directions: Please provide the new information in the following fields. Leave field(s) blank for information that should not change.

Account Holder Information


Account Holder Name*
If the legal name of the account holder has changed, you must attach a copy of the legal document approving the name change (e.g., marriage certificate).
No File Chosen
File uploads may not work on some mobile devices.
Did your email address change?*

Date of Changes

Please give date(s) of change(s) described in this form.

Signature Page


Signature

I certify the information provided in this form, including any supporting documentation, is truthful and accurate. I further understand that any false statements or documentation may result in the student’s account being frozen, the student being removed from the IEA Program, closure of the student’s IEA account, and/or forfeiture of all funds remaining in the account. I further understand that if any false statements or documentation is provided, the department may prohibit the student and/or parent/guardian from enrolling in the IEA Program and/or being an IEA account holder in the future.


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