Certificate Of Financial Responsibility Form
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1
2Certificate of
Financial Responsibility
Personal
Please print your full name exactly as it appears on your passport or birth certificate. We cannot issue your immigration
document (I-20 or DS-2019) until we receive this form from you. Please complete both sides of the form and attach all
Information
required documents. Return the form with your admissions application.
Male
Applicant’s Name* ____________________________________________________________________________
Female
First
Middle
Last (family name)
Date of Birth*
City and Country of Birth* _____________________________________
Month/Day/Year
Country of Citizenship* ________________________________________________________________________________
Country of Legal Permanent Residence* ___________________________________________________________________
E-mail __________________________________________ Telephone ___________________ Fax ____________________
Foreign Residence Address* (Note: This information is required, even if you are currently living in the United States.) _____
____________________________________________________________________________________________________
U.S. Address (if applicable) _____________________________________________________________________________
____________________________________________________________________________________________________
To which address would you like your I-20/DS-2019 mailed? __________________________________________________
Previous or current Mason identification number (if known) ___________________________________________________
Student Type: Freshman Transfer Graduate
*Mandatory information
Immigration
What type of immigration document are you requesting from Mason?
Information
I-20 (F-1 status) DS-2019 (J-1 status)
Please attach a copy of your passport identification page or if your passport is unavailable, a copy of your birth certificate.
Are you currently in the United States? Yes* No
*Please attach a copy of your current immigration document (Form I-20, DS-2019, or other) and I-94 card.
If yes:
1. What is your current immigration status? F-1 J-1 Other: ___________________________________________
2. What is your SEVIS ID number if you currently have one? _________________________________________________
3. If currently in F-1 or J-1 status, please list school or university you are attending. _______________________________
_________________________________________________________________________________________________
4. Are you planning to leave the United States before coming to Mason? Yes No
5. If yes, when? ______________________________________________________________________________________
Information
If your family will accompany you, you must show evidence of an additional U.S. $5,000 per year for your spouse and
about
U.S. $2,500 for each child. For each dependent, please attach a copy of passport identification page or birth certificate.
Dependents
Please complete:
I plan to come alone.
Who Will
I plan to bring the following dependents who will enter the United States with me. (Complete below.)
Accompany
The following dependents are currently with me in the United States and will remain with me.
You
Name _________________________________________________________________________________________________
Last (family name)
First
Middle
Date of Birth _______________________________Country of Citizenship _______________________________________
City and Country of Birth ____________________Country of Legal Permanent Residence __________________________
(Please continue on separate sheet if needed.)
Spouse (
Child (
Male or Female
Male or Female
)
)
Funding
• You must demonstrate that you have sufficient funds available for your academic and living expenses.
• You or your sponsor will be responsible for all payments according to scheduled Mason payment dates for each semester.
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Parent category: Business