The Graduate School (Page 2 of 2) in pdf

List the persons financially dependent upon you, who will be coming to the US with you. You must also provide a copy of

their passport.

Name (Family name in capital letters)

Country of Birth

Date of Birth

Relationship

Country of citizenship

Indicate sources and amounts in United States dollars of additional funds available to you in case of you have an emergency

after your arrival in the United States. (This must be filled out.)

Describe your arrangements to assure funds for your return transportation to your home country after your period of study in

the United States. (This must be filled out.)

CERTIFICATION BY STUDENT (An I-20/IAP-66 form cannot be issued on the basis of this information unless you sign

and date the statement.)

I hereby certify that the information given in this form is complete and accurate to the best of my knowledge. I understand

that future financial assistance by the Graduate School may be contingent on the accuracy of the information provided.

Signature_________________________________________

Date _____________________________

CERTIFICATION BY SPONSOR ( The following certification must be signed by the person providing any part of your

funds or by an official of the agency, organization, or firm sponsoring your study in the United States. If the sponsor wishes

to supplement the statement or indicate any special conditions or limitations of the sponsorship, a letter of explanation may

be attached. If more than one sponsor is aiding the applicant, the following certification must be copied and signed by each

sponsor.)

This is to certify that I have read the information on this form and the statements made by the applicant. I am (or my agency,

organization, or firm is) prepared to provide funds to support the applicant while studying at Northern Illinois University for

the period of time and to the extent indicated.

Sponsor 1

Signature ________________________________________

Date _______________________________________

Name (print or type) _______________________________

Relationship to Applicant________________________

Address________________________________________________________________________________________

Sponsor 2

Signature ________________________________________

Date _______________________________________

Name (print or type) _______________________________

Relationship to Applicant________________________

Address________________________________________________________________________________________

Complete statement, with sponsor certification if needed should be sent to:

The Graduate School

Northern Illinois University

DeKalb, Illinois 60115-2864, U.S.A.

Fax: 815-753-6366

The Graduate School Page 2