Financial Verification Form Office Of Admissions And Recruitment printable pdf download

Financial Verification Form

2016-2017

STUDENT INFORMATION

Last name/surname ____________________________ First name _____________________________ Middle name ____________________

Campus ID# (if known) __________________________

Country of Citizenship ___________________________________

Permanent Home Address (outside of the United States)

Mailing Address (if different from the permanent home address)

_________________________________________________

Birth Information

Birth Month______ Date______ Year________ Birth city___________________________ Birth country________________________

Applicant’s Declaration: I certify the information below is correct and complete. I shall notify UW–Madison of any changes in my financial support.

I understand that any misrepresentation may result in the university revoking my admission or terminating my enrollment.

Student Signature____________________________________

Today’s Date (mm/dd/yyyy)____________________________

SPONSOR INFORMATION

Personal Sponsor(s)

Can be a relative, friend, or employer. Financial document must be an official bank letter verifying at least $54,259 (USD) on deposit.

Sponsor #1

Last Name______________________________

First Name_______________________________

Relationship to Student____________________

Amount on Deposit (USD) $________________

Sponsor #2

Last Name______________________________

First Name_______________________________

Relationship to Student____________________

Amount on Deposit (USD) $________________

Total Amount on Deposit from all personal sponsors (USD) $________________

Agency Sponsor

Can be a government, educational institute, or academic organization. Each sponsor must submit a letter stating intent to cover expenses for the

student with an exact dollar amount. If scholarship does not cover all living expenses and tuition costs, complete the personal sponsor

section (above) for expenses not covered. If student is studying on J‐1 visa, the sponsor should note that in the letter of support.

Agency Name

_______________________________________

Agency Address

Contact Person

_______________________________________

_________________________________________________

Email Address

_______________________________________

_________________________________________________

Phone Number

_______________________________________

_________________________________________________

Submit this form with the required documentation to:

Mail:

University of Wisconsin‐Madison, Office of Admissions and Recruitment

Fax:

608‐265‐5154

Email: onwisconsin@admissions.wisc.edu

702 West Johnson Street, Suite 1101 Madison, Wisconsin 53715–1007

Rev 10/21/2016

Financial Verification Form Office Of Admissions And Recruitment

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