Fillable Form Is-90, F-1/j-1 Departure Verification printable pdf download

Form Is-90, F-1/j-1 Departure Verification

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Form IS-90, F-1/J-1Departure Verification

This notification is for immigration reporting purposes only and does not replace the student’s responsibility to comply with the

University’s official drop-add policy.

Please complete this fillable form after you have completed your studies or the sponsorship of your J-1 program has ended. F-1

students on OPT or J-1 students on Academic Training will not need to complete this form until that immigration benefit has ended.

This form may be returned via email to is@clemson.edu.

Part I. Student Information

1. Student/Exchange visitor’s Name

2. CID No. C

3. SEVIS ID No. N00

6. Email

@clemson.edu

4. Degree

5. Major

F-1

J-1

H-4

Other

7. Phone No

8. Nonimmigrant status

9. Departure U.S. Date

10.

Return Date

(If applicable)

13. I-20/DS-2019 End Date

11. Country I am going to

12. I-20/DS-2019 Start Date

Part II. Reason for Departure (Check the box that applies to you)

I have completed my program and I will be returning to my home country. I authorize IS to complete my program in SEVIS. My

permanent address in my home country is ___________________________________________________________________________

My period of OPT/Academic Training will expire on (date)

. I will return to my country within the grace period

(For continuing students with good immigration standing only) I must depart the U.S. (during a regular semester) and will return to

continue my studies at CU within five (5) months and my department has agreed to my temporary leave of absence. I plan to register for

20 _____ semester. I ask IS to maintain my F-1/J-1 SEVIS record

the

Transfer to a new school in the US. Please list school

(Please do not submit this form if you are going to apply for OPT or Academic Training)

I have changed my non-immigrant status. I have attached a copy of my approval notice for my new status

I have filed an Adjustment of Status application, I-485 and I opt not to maintain my F-1/J-1 status. I have attached a copy of Notice

of Receipt for my I-485 filing from USCIS

I must depart the U.S. and will not be returning within five (5) months. I understand that my SEVIS record will be terminated. I will

need to contact IS to request a new form I-20 should I decide to return to the U.S. to attend CU.

Other

Part III. Emergency Contact Information (Immediate family preferred... e.g. parents/guardians, etc.)

Foreign

Name:

Relationship:

Phone #

Alternate Phone #:

Country:

Email:

Part IV. Signature

Signature

Date

(864) 656-3614

IS@Clemson.edu

Rev. (LOD) 03/12/14

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Form Is-90, F-1/j-1 Departure Verification

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