Request For Dependent Ds-2019 Form
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1Oklahoma State University
International Students and Scholars
Request for Dependent DS-2019
Please complete the following form and attach required documentation for all dependents requested.
(Please complete and attach additional forms if necessary)
□ Copy of dependent’s biographical page of passport
□ Financial Guarantee
Spouse: $850 per month ($10,200/year), Child: $450 per month ($5,400/year)
J-1 Exchange Visitor’s Last Name: ________________________ First Name: _____________________
Dependent Information:
1. Last Name: ___________________________ First Name: ______________________________
Relationship:__________________________ Date of Birth (mm/dd/yyyy):_________________
City of Birth: __________________________ Country of Birth: __________________________
Country of Citizenship: ___________________ Email*: _______________________________
2. Last Name: ___________________________ First Name: ______________________________
Relationship:__________________________ Date of Birth (mm/dd/yyyy):_________________
City of Birth: __________________________ Country of Birth: __________________________
Country of Citizenship: ___________________ Email*: _______________________________
3. Last Name: ___________________________ First Name: ______________________________
Relationship:__________________________ Date of Birth (mm/dd/yyyy):_________________
City of Birth: __________________________ Country of Birth: __________________________
Country of Citizenship: ___________________ Email*: _______________________________
*Dependents who are under the age of 18 are not required to provide an email address.
I understand that:
1. I am responsible for checking in with the ISS Office within 10 days of the first arrival and prior to the final
departure of all J-2 dependents.
2. All J-2 dependents must secure and maintain health insurance meeting the minimum US Department of
State requirements for the duration of their stay in the US.
3. I am responsible for providing the ISS Office with a current address in the event that any or all of my
dependents are living separately from me.
“I hereby certify the above information is true and accurate.”
Signature of Student:___________________________________________ Date: __________________
For ISS Use Only:
Date Received: ____________ Received by: ____________ Date DS-2019 Issued: ____________
6/19/15
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