State of Tennessee

Participating Schools Required Textbooks Affidavit Form

If a participating school requires account holders to purchase textbooks for the student from a retail source, account holders must submit the Participating Schools Required Textbooks Affidavit Form to the department before submitting the expense report.

Purchases of required textbooks from a retail source must be reported on an IEA Expense Report and an itemized receipt must be submitted with the expense report (please see Chapter 7 for detailed instructions for filling out expense reports).
Account holders are not required to submit a Textbooks Affidavit Form if the school is providing the textbooks and charging the account holder a textbook fee.

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

ED5532 RDA 11163

Directions: Please provide the information in the fields below and attach appropriate documentation. A Participating School Required Textbooks Affidavit is required for each required textbook.

Student Name*

First Name

Last Name

Acount Holder Name*

First Name

Last Name

Account Holder Email Address*

Date*

Name of Participating School*

Required Textbook Information

Name of Textbook*

Course*

Publisher*

Date of Publication*

Direct Weblink to a Webpage Describing the Textbook*

Supporting Documentation

The account holder must submit documentation proving that the textbook(s) listed above is required by the participating school (e.g., a letter from the school principal which details the requirement).

Documentation of the Participating School Requirement*

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IEA Account Holder Agreements

Agreement Statements

By signing your initials, you are acknowledging your agreement to each statement.

I attest that the textbooks listed above are required by the participating institution that the student attends. I understand that textbooks that are not required are an inappropriate use of IEA funds.

Initials*

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 future.

Initials*

IEA Account Holder Signature*

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Date*