Southwestern University Certification of Finances

1. Student Information

Mr.
Mrs.

Ms.
Miss

family name (surname) first (given) name middle name

birthdate (mm/dd/yyyy) place of birth (please include country) country of citizenship

2. Permanent Address 3. Mailing Address (If different than permanent address)

number and street number and street

city/town/locality state/province zip/postal code city/town/locality state/province zip/postal code

country country

4. Expected VISA Type

F - academic or language training
J - exchange visitor
A or G - diplomatic or official

M - non-academic vocational
PR - immigrant
Other (specify):

5. Student Funding Sources 6. Certification of Funding Sources

Enter the expected amount of annual support from the sources listed below. Enter the This is to certify that I have read the information furnished by the applicant on this form,

amounts in US dollars. Please print all entries. Use additional sheet of paper for expla- that it is a true and accurate statement, and that the funds are available and will be

nations, if necessary. provided as indicated. ** Signatures are required for all sources of funding**

5A - Personal or Family Savings

name of bank signature of bank official date

title

$ $ $ $
FIRST YEAR SECOND YEAR THIRD YEAR FOURTH YEAR address of bank
assured support projected support projected support projected support

5B - Parents (other than savings)

please describe source of funding father’s name mother’s name

signature of parent date

$ $ $ $
FIRST YEAR SECOND YEAR THIRD YEAR FOURTH YEAR address

assured support projected support projected support projected support

FOR OFFICE USE ONLY

This is to certify that I have reviewed the declara- signature of bank official date address of bank

tion and attached documents, if appropriate, and

approve issuance of a Certificate of Eligibility.

title name of institution
5C - Sponsors (from sources other than parents)

please describe source of funding sponsor’s name

signature of sponsor date

address

$ $ $ $
FIRST YEAR SECOND YEAR THIRD YEAR FOURTH YEAR relationship of student to sponsor

assured support projected support projected support projected support

5D - Your Government

$ $ $ $
FIRST YEAR SECOND YEAR THIRD YEAR FOURTH YEAR name of agency (enclose with this form a signed copy of your letter of award)

assured support projected support projected support projected support

5E - Totals for Sections 5A, 5B, 5C and 5D

$ $ $ $
FIRST YEAR SECOND YEAR THIRD YEAR FOURTH YEAR
assured support projected support projected support projected support

6. Other Information

6A What is the present exchange rate of your country’s currency to the US dollar? (example: 12.90 pesos = $1 US) = $1 US

6B Does your government currently impose restrictions on exchange and release of funds for study in the U.S.?
YES
NO

if you answered “Yes,” please describe the restrictions

6C Do you have a source for emergency funds once you arrive in the U.S.?
YES
NO

$
if you answered “Yes,” please name the source amount available in US dollars

6D How will you pay for your transportation to the U.S.?

6E What is the total amount of money you expect to have when you arrive at this institution? US $

6F Do you plan to remain in 6G If remaining in the U.S., do

YES
NO
YES
NO
the U.S. during the summer? you plan to attend summer school?

6H What are the sources and amounts of support (in US dollars) available to you during the summer?

$ $ $
source 1 amount source 2 amount source 3 amount

A CERTIFICATE OF ELIGIBILITY (form I-20 or IAP-66) will I certify that the information on this form is true, correct and com-
not be authorized until this form is completed and returned to plete. I understand that any misrepresentation may be cause for
Southwestern University. Southwestern will attach a copy of this refusing or revoking admission.
form to your Certificate of Eligibility. Both the form and the certifi-
cate must be shown to the U.S. Consul to obtain a visa.
signature of student date