Northeastern University Request To Change Funding, Replace Ds- 2019, Or Issue J-2 Dependent Ds-2019 (Form D) Page 2
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4Request to Change Funding, Replace DS-
2019, or Issue J-2 Dependent DS-2019
(Form D)
Part I: Personal Information
Scholar’s Name: _________________________________________________________________________________________
Last/Family Name
First/Given Name
Middle Name
NU Department: ______________________________________________________
Scholar Home Address: ___________________________________________________________________________________
Telephone: _________________________________________
Email: ___________________________________________
Has the scholar, if applicable, applied for 212 (e) waiver?
Yes*
No
Not Applicable
List the amounts from each source according to the list below, including additional funds required for dependents, if
applicable. The total should be an estimate of expenses for the full length of the program.
Please note, as per federal regulation, the J-1 Scholar must submit documentation to the OGS for all received or anticipated
scholarships, fellowships, etc. for the purpose of exchange, regardless of whether the scholar possesses sufficient personal
funds for the J-1 program. Receipt of direct funding from the U.S. or foreign government for the purpose of exchange will
subject the scholar to 212 (e). Failure to disclose receipt of government funding to the appropriate official (Consular Officer,
RO, ARO) can be a material representation that may lead to detrimental consequences.
Part II: Financial Declaration and Certification
Funds
Name of Source
Amount (U.S. Dollars)
Required Financial Documents
Northeastern Salary,
$
Appointment Letter
Stipend, Honorarium,
etc.*Prorate annual salary
to reflect exact time period
of DS-2019 if it is less or
more than one year.
Northeastern
$
Appointment Letter or Accounts
Reimbursements
Payable Forms
U.S. Government Agency
$
Letter of Funding
International Organization
$
Letter of Funding
Home Country
$
Letter of Funding
Government
Bi-national Commission of
$
Letter of Funding
Home Country
Other Organizations
$
Letter of Funding
Personal Funds
$
Bank Statements
Total
-
$
Office of Global Services, 405 Ell Hall, 360 Huntington Ave, Boston, MA 02115
northeastern.edu/ogs | ogs@northeastern.edu | (p) 617.373.2310 | (f) 617.373.8788
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