Dated:

FINANCIAL DATA QUESTIONNAIRE

STUDENT VISA APPLICATION

AMERICAN CONSULATE GENERAL

I, (Name of CA), Fellow Member of the Institute of Chartered Accountants of

India, do hereby certify that I have reviewed the financial condition of (Father’s
Name) and (Mother’s Name), parents of ​(Candidate’s Name) with a view to
establishing their ability to pay the educational cost of their son ​(Candidate’s Name)
for the M.S. (Computer Science) program of study at the (UNIVERSITY NAME),
University Address). which has been estimated to be ​US $ 23,422 ​per year as per the
I-20 issued by the University.

Sl SOURCES OF FUNDS US $ INDIAN REFERENCE

Rs. (Annexures)
1 Scholarship Nil Nil --
2 Savings in India
(a) Movable Assets
(b) Immovable Assets
3 Personal/ Family savings from --
abroad
4 Current Income from India
5 Current Income from abroad --
6 Loans --
7 Other Sources --
TOTAL --

Notes:
[1] Exchange Rate:
[2] Amounts are rounded off to the nearest Rupee or Dollar as the case may be
[3] The applicant is sponsored by his parents
 :: 2 ::

MOVABLE ASSETS
ANNEXURE – I

Sl. NATURE OF ASSET US $ Indian

Rupees Rs.
1. Balance in Savings Bank Account No. 1/64 of
(Father’s Name) (Father of the applicant) with State
Bank of India, (Branch Name), (City), (State) (as
per Bank Certificate)

2. Post Office Savings Deposit (Monthly Income

Scheme) A/c No. 4033 in the names of (Father’s
Name) and (Mother’s Name) (Parents of the
applicant) with (Post Office Name), (City) (as per
Post Office passbook)

3. Fixed Deposits in the names of (Father’s Name) and

(Mother’s Name) (Parents of the applicant) with
State Bank of India, (City) (3 nos.) (as per FD
receipts)
▪ CSP XXXXXX
▪ CSP/B XXXXXX
▪ CSP/B XXXXXX

4. Recurring Deposits in the names of (Father’s Name)

and (Mother’s Name) (Parents of the applicant) with
State Bank of India, (City) (as per Recurring
Deposit Receipt)

5. General Provident Fund amount vide PF No. 9704

with Sr. Deputy Accountant General (A&E),
(State), of (Mother’s Name) (Mother of the
applicant) (as per GPF statement)

6. Sum Assured values of LIC premium accounts in

the names of (Father’s Name) and (Mother’s Name)
(Parents of the applicant) (as per LIC Policy
receipts)
▪ Policy No. XXXXXX
▪ Policy No. XXXXXX
▪ Policy No. XXXXXX
▪ Policy No. XXXXXX
Balance C/d.
 :: 3 ::

Balance b/d.

7. Investment value of National Savings Certificates in

the names of (Father’s Name) and (Mother’s Name)
(Parents of the applicant) with (Post Office Name),
(City) (20 nos.) (as per NSC Certificates XXXX,
YYYYY, ZZZZZ)

TOTAL
 :: 4 ::

IMMOVABLE ASSETS
ANNEXURE – II

Sl. NATURE OF PROPERTY US $ Indian

Rupees Rs.
1. Urban site belonging to (Father’s Name) (Father of
the applicant) with residential buildings bearing
Patta No. 42/709 measuring 0.0975 acres situated at
(Locality), (City). (as per Building Valuation
certificate given by Assistant Engineer (Buildings),
PWD, (City) and Land Valuation certificate given
by Assistant Survey and Settlement Officer,
Directorate of Settlement and Land Records, (City))

2. Semi-urban homestead land belonging to (Father’s

Name) (Father of the applicant) bearing Patta No.
106/1464 measuring 0.56 acres situated at (Place).
(as per Land Valuation certificate given by SDC,
(Place), (District.)

3. Agricultural land belonging to (Father’s Name)

(Father of the applicant) bearing Patta Nos. 98/75,
98/404, 98/94, 98/980, 98/477, 98/471 (6 pattas)
together measuring 7.005 acres situated at
Kangmong Village, (City) West. (as per Land
Valuation certificate given by SDC, (District)

4. Agricultural land belonging to (Father’s Name)

(Father of the applicant) bearing Patta Nos. 106/295
and 106/411 together measuring 1.24 acres situated
at Hiyangthang Village, (City) West. (as per Land
Valuation certificate given by SDC, (District)

5. Agricultural land belonging to (Father’s Name)

(Father of the applicant) bearing Patta Nos.
32/795/1104 and 36/764 together measuring 3 acres
situated at Keinou Village, Bishenpur district. (as
per Land Valuation certificate given by SDC,
(District)

TOTAL
 :: 5 ::

CURRENT INCOME FROM INDIA

ANNEXURE – III

Sl. US $ Indian
Rupees Rs.
1. Net Annual Salary income of (Father’s Name)
(Father of applicant) as (Job title) (as per Form-16
and Salary Certificate)

2. Net Annual Salary income of (Mother’s Name)

(Mother of applicant) as (Job title) (as per Form-16
and Salary Certificate)

3. Annual Agricultural income from cultivable lands.

TOTAL

I hereby declare that the above certificate has been given by me on the basis of
the original documents, affidavits of the student’s parents, relevant certificates and
property documents. After reviewing the financial condition of ​(Father’s Name) &
(Mother’s Name)​, I find them financially sound to meet the education and living
expenses of their son ​(Candidate’s Name) for his M.S. (Computer Science) program
at the (University Name).

(Chartered Accountant)
(Round Seal)