Uscis Declaration & Certification Of Finances - Student'S Information Form

DECLARATION & CERTIFICATION OF FINANCES

Student’s Information

A CERTIFICATE OF ELIGIBILITY (1-20 or IAP-66 will not be authorized until this form is completed and returned to the institution to which you are applying. The institution

will attach a copy of this form to your CERTIFICATE OF ELIGIBILITY. Both the form and certificate must be shown to the U.S. Consul to obtain visa.

STUDENT’S NAME:

DATE OF BIRTH:

Last (Family)

First

Middle

Month

Day

Year

Permanent Address:

Mailing Address (If Different):

EXPECTED VISA STATUS:

Student (F-1) ______ Exchange Visitor (J-1) ______ Other (Specify) ______________________________________________________

Students will reside at this address until given date:

PLACE OF BIRTH:

COUNTRY OF CITIZENSHIP:

DECLARATION OF FINANCE: OFFICAL CERTIFICATION SOURCES OF FUNDS AND AMOUNTS

Enter amounts in US$. Please PRINT all entries. Use an additional sheet of paper for explanations, if necessary

ASSURED

This is to certify that I have read the information furnished by the

STUDENT’S SOURCE OF

PROJECT SUPPORT

SUPPORT

applicant on this form, that it is a true and accurate statement, and that

FUNDS

the funds are available and will be provided as indicated.

st

nd

rd

th

1

Year

2

Year

3

Year

4

Year

Personal or Family Savings

Name of Bank Official: _____________________________________

Title: ____________________________________________________

NAME OF BANK: _____________

Name of Bank: ____________________________________________

_____________________________

Address of Bank: __________________________________________

_____________________________

A bank official’s signature is

________________________________________________________

required on the certification. If the

Signature of Bank Official: __________________________________

student is partially or totally

Date: __________________________

supported by personal savings.

Parent Name: _____________________________________________

Parents

For resources other than savings

Signature of Parent: ________________________________________

Parent Name: _____________________________________________

Parent Name: _________________

Signature of Parent: ________________________________________

Parent Name: _________________

Address: _________________________________________________

Please explain source: __________

_________________________________________________________

_____________________________

_____________________________

Date: __________________________

Relationship to Student: _____________________________________

Sponsors

For resources other than savings

Signature of Sponsor: ______________________________________

Sponsor’s Address: ________________________________________

Sponsors Name: _______________

________________________________________________________

Please explain source: __________

Date: __________________________

_____________________________

Your Government

Enclosed with this form is a signed copy of your

Name of Agency: ______________

letter of award

_____________________________

Please explain source: ______________________________________

Other

_________________________________________________________

Merit Scholarship From

Enclosed with Acceptance Letter

Admission

TOTAL:

*Estimated 2016-17 expenses. Final costs will be confirmed in March.

$52,850*

WARNING: Providing false information may jeopardize a student’s visa status and furthermore may result in an institution revoking its initial decision to enroll the students.

I certify that the information provided here is correct and complete

STUDENT NAME:

SIGNATURE OF STUDENT: ______________________________________________________________________________

DATE: __________________________

This is to certify that I have reviewed the declaration and attached documents, if

Signature of

College Official: ___________________________________________________________

appropriate, and approved issuance of a Certificate of Eligibility.