I-20 Request Form
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1CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA
I-20 Request Form
This confidential I-20 Request form must be completed and submitted as part of the Cal Poly Pomona Admissions
application process. A final decision about admission for a foreign applicant and the issuance of a Certificate of
Eligibility (Form I-20) for a student visa requires verification of financial resources. California State Polytechnic
University School Code LOS214F00334000.
Part I Applicant Information
Bronco Number: ___________________________ Major: ________________________ Quarter/Year Applied: _____________
Family Name: ______________________________First Name: ____________________________ Middle Name: ____________
NAME MUST MATCH PASSPORT EXACTLY
Date of Birth: Month: _______________________ Day: _______________ Year: _____________ Male □
Female □
Country of Birth: ____________________________________________ Country of Citizenship: __________________________
U.S. ADDRESS (if applicable):
Street Address: ___________________________________________________________________________________________
City: _________________________________
State: ____ Postal Code: _______________Phone ______________________
HOME COUNTRY ADDRESS:
Street Address: __________________________________________________________________________________________
City: ____________________________________________Province/Territory: _______________________________________
Country: _________________________________________________ Postal Code: _______________ Phone: ______________
Part II
Verification of Financial Support
APPROXIMATE COSTS FOR AN ACADEMIC YEAR
Includes estimated costs of campus fees, books, supplies, room and board, personal expense, transportation costs,
and tuition. This estimate is based on enrollment in the minimum number of units for each term. Some academic
programs require students to take more than the minimum number of units. For calculating costs, see the Student
Accounting & Cashiering Services website at A spouse requires an
additional $5000 and a child an additional $3000 of support.
Undergraduate International Student
Graduate International Student
Living Expenses $19,352
Living Expenses $19,352
Tuition & Fees
15,800
Tuition & Fees
13,700
TOTAL $35,152
TOTAL $33,052
Verification of sufficient funds to support one year of educational costs is required. Attach a bank
statement(s) or written letter from a bank to this completed form to verify the availability of funds.
1.
Name of Sponsor______________________________________ Relationship___________________________
2.
Are you currently on your home country and planning to apply for an F-1 visa?
Yes ___
No ___
3.
Are you transferring from a school in the U.S.?
Yes ___
No ___
If yes, do you have an active SEVIS (I-20) record? Yes ___
No ___
If yes, request to have the SEVIS record must be transferred from your current school to CPP.
What is your final date of study at your current school? ____________
4.
Do you have dependents with you while studying in the USA? If yes, please print names and relationships to
you on the line below (include a copy of dependents’ passport picture and information pages:
_____________________________________________________________________________________________
___________________________________________________________
______________________
SIGNATURE
DATE
Rev 10/2015
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