Declaration & Certification Of Finances Form
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1DECLARATION & CERTIFICATION OF FINANCES
Student’s Information
A CERTIFICATE OF ELIGIBILITY (1-20 or IAP-66 will not be
authorized until this form is completed and returned to the institution to
which you are applying.
STUDENT’S
Mr.
The institution will attach a copy of this form to your CERTIFICATE OF
NAME
Mrs.
ELIGIBILITY. Both the form and certificate must be shown to the U.S.
Miss.
Consul to obtain visa.
Last (Family)
First
Middle
Permanent
DATE OF BIRTH
EXPECTED VISA
Address
STATUS:
Mailing
Month
Day
Year
Student (F-1) ______
Address
(if Different)
Exchange Visitor (J-1) ______
PLACE OF BIRTH
Students will reside at this address until
(Give Dates)
Other (Specify) ________
CITIZENSHIP
DECLARATION OF FINANCE
OFFICAL CERTIFICATION SOURCES
Enter amounts in US$. Please PRINT all entries. Use an additional sheet of paper for explanations, if necessary.
OF FUNDS AND AMOUNTS
STUDENT’S SOURCE OF FUNDS
ASSURED
PROJECT SUPPORT
This is to certify that I have read the information furnished by
the applicant on this form, that it is a true and accurate
SUPPORT
statement, and that the funds are available and will be
st
nd
rd
th
1
Year
2
Year
3
Year
4
Year
provided as indicated.
Personal or Family Savings
Signature of
Bank Official
NAME OF BANK
Title
A bank official’s signature is
Name of Bank
required on the certification. If
Address of Bank
the student is partially or totally
Date
supported by personal savings.
Parent’s
Parent’s Signature is required.
For resources other than savings
Signature of
Parent
Name
Address
Name
Please explain source:
Date
Sponsors
Sponsor’s Signature is required.
For resources other than savings
Signature of
Guarantor
Sponsor
Name
Address
Name
Relationship of Guarantor to Student
Please explain source:
Date
Your Government
Enclosed with this form is a signed copy of
your letter of award
Name of Agency
(Other Specify)
Enclosed with this form is a signed copy of your
Scholarship
letter of award
TOTAL
51,260
WARNING: Providing false information
may jeopardize a student’s visa status and
I certify that the information provided here is correct and complete
furthermore may result in an institution
revoking its initial decision to enroll the
SIGNATURE OF STUDENT
DATE
students.
This is to certify that I have reviewed the declaration and
Signature of
attached documents, if appropriate, and approved issuance of a
College Official
Title
Certificate of Eligibility.
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