International Student Financial Statement Page 2

INTERNATIONAL STUDENT FINANCIAL STATEMENT

(International Applicants only)

Part I Print in ink or type

1. Name of applicant _______________________________________________________________________________________________________________________________

Mr. Ms.

Last Name/Surname

First/Given

Middle

2. Permanent address _______________________________________________________________________________________________________________________________

COST OF ATTENDANCE 2012–2013

3. Birthdate ________ / ________ / ________

Month

Day

Year

Tuition

$43,350

4. Country of citizenship ______________________________________________________________

Fees

1,125

Room and Board

12,450

Books and Supplies

2,545

Ë

Ë

5. Does your country restrict dollar exchange?

Yes

No

Laptop (purchase price)

1,550

$ ________________________________

What is the maximum dollar amount permitted for a student?

Total:

$61,020

6. Total amount of U.S. dollars you expect to bring with you upon arrival

The financial costs of attending Rensselaer

(tuition, room, meals, and books must be paid at the beginning of the semester). $ ________________________________

rise approximately 6% each year. Rensselaer

will communicate the exact costs to each

7. Do you have a source within the U.S. for emergency funds

applicant at the time of admission.

once you arrive in this country?

Ë

Yes

Ë

No

8. If yes, name source _____________________________________________________

Amount available in U.S. $ _______________________________________________

Part II Complete each relevant item below. Sign and date the form after (C). Enter amount of assured support available for each year of study in U.S. dollars.

Source of Funds

Year 1

Year 2

Year 3

Year 4

Required Verification

Personal Savings

1. Bank Statement of Account.

2. Complete (A) and (C) below.

Name of bank _______________________________________________________

Account holder _____________________________________________________

$______________ $______________ $______________ $______________

Family/Relative/Sponsor

1. Bank Statement of Account.

2. Complete (A), (B), and (C) below.

Name ______________________________________________________________

Name ______________________________________________________________

$______________ $______________ $______________ $______________

Scholarship/Loan awarded by

1. Official award letter. See

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

instructions on reverse side.

2. Loan approval letter. See

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

instructions on reverse side.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

$______________ $______________ $______________ $______________

3. Complete (C) below.

Government/Employer/Other

1. Official letter of support. See

instructions on reverse side.

Name of sponsor ____________________________________________________

2. Bank statements, affidavits,

Other ______________________________________________________________

or sworn statements.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

$______________ $______________ $______________ $______________

3. Complete (C) below.

$______________ $______________ $______________ $______________

Totals

Verification

A. This is to certify that the funds above are on deposit or are being held in the name of the applicant, family members, or sponsors (named above) at the savings insti-

tution named below. (Verification of amounts is without liability for the bank or its officials). Attach separate statement of accounts with official signature/seal.

Name of bank ____________________________________________________________________________________________________ Date _________________________

Bank official’s title ___________________________________________________ Bank official’s signature/seal ___________________________________________________

B. This is to certify that I (we) the undersigned have agreed to provide funds indicated above to the applicant for the purpose of full-time study at Rensselaer

Polytechnic Institute and that I (we) are submitting bank statements indicating the availability of these funds. I (We) further understand that Rensselaer

cannot provide ANY financial assistance to the applicant and that I (we) must provide these funds for the duration of the applicant’s course of study. If

the commitment is not met, the student may be subject to dismissal from the University for non-payment.

Sponsor signature _______________________________________________ Date _____________ Relationship to applicant ______________________________________

Sponsor signature _______________________________________________ Date _____________ Relationship to applicant ______________________________________

C. This is to certify that the information given on this form is complete and accurate to the best of my knowledge. I am fully aware that any false

or misleading statement will result in an automatic denial of admission, or cancellation of registration following enrollment.

Applicant’s signature ______________________________________________________________________________________________ Date _________________________