Applicant Information Provide your name exactly as it appears on your passport. Family/Last Name _________________________________ First Name _____________________________ Middle Name _______________________ Country of Citizenship ________________________ UCLA ID # _____________________________ Date of Birth ________________________ Month | Day | Year Dependent(s) Information If Applicable Do Not Complete this Section if you do not have dependent(s) or will not be applying for F-2 or J-2 Visas for your dependent(s) at this time. If your dependent(s) will join you in the U.S. at a future time, you may request F-2 I-20s or J-2 DS-2019s for your dependent(s) from DCISS after your arrival to UCLA. List your dependents who will be accompanying you to the U.S. on F-2 Visa status. Dependent(s) listed here will be issued certificate of eligibility(s) required to apply for F-2 or J-2 Visas from a U.S. Embassy or Consulate. Additional proof of financial support is required: Spouse - $4,500 Children - $2,500 Per Child ■ [1] Dependent’s Name (as it appears on passport) _____________________________________________________________ Family/Last Name | First Name | Middle Name Country of Birth _________________Citizenship __________________ Date of Birth _________________________________________________ Month | Day | Year Relationship to Applicant ______________________________________ ■ [2] Dependent’s Name (as it appears on passport) _____________________________________________________________ Family/Last Name | First Name | Middle Name Country of Birth _________________Citizenship __________________ Date of Birth _________________________________________________ Month | Day | Year Relationship to Applicant ______________________________________ ■ [3] Dependent’s Name (as it appears on passport) _____________________________________________________________ Family/Last Name | First Name | Middle Name Country of Birth _________________Citizenship __________________ Date of Birth _________________________________________________ Month | Day | Year Relationship to Applicant ______________________________________ Source of Financial Support Please indicate your source(s) of funding as applicable. At least one source of funding must be indicated; not all sources of funding may apply to you. Personal Funds Amount of personal funds as U.S. $ _______________ stated on your bank statement. Name of Bank(s) ___________________________________________ [*Must submit valid personal bank statement, translated in English.] Family or Individual Sponsor’s Funds Sponsor’s Guarantee U.S. $ _______________ “I _________________________________________, guarantee that the funds Please print full name indicated here will be available for the applicant listed for tuition, fees and living expenses at UCLA. If the applicant will be attending UCLA Summer Sessions, the guarantee will also include Summer Session fees.” Signature of Sponsor _____________________________________________ Relationship to Applicant ___________________________________ Name of Sponsor’s Bank(s) __________________________________ [*Must submit sponsor’s valid bank statement, translated in English.] UCLA Department Funds Amount to be Awarded U.S. $ ________________ Type of Award(s) ________________________________________ [*Must submit department funding letter or UCLA award/offer letter.] Sponsoring Organization or Government Funds Amount to be Awarded U.S. $ ________________ Name(s) of Sponsoring Entity _______________________________ [*Must submit copy of the award letter issued from sponsoring entity specifying the amount and duration of funds.] Total Financial Support U.S.$ ____________ Signature of Applicant: “I hereby confirm the information indicated in this statement is true to the best of my knowledge and that I will have the funds stated to attend UCLA. I understand that my enrollment at UCLA may be jeopardized if any information indicated here is found to be incomplete or false. I will notify UCLA immediately if there are any changes in my financial situation.” Signature of Applicant __________________________________________________________________ Date ________________________________ UCLA ■ Dashew Center for International Students & Scholars (DCISS) ■ 106 Bradley International Hall ■ 417 Charles E. Young Drive West, Los Angeles, CA, 90095‐1379 ■ 310‐825‐1681 ■ internationalcenetr.ucla.edu Confidential Financial Statement This form must be completed and signed to verify evidence of financial support for the issuance of a UCLA I-20 or DS-2019. Signatures, bank statement(s) dated within the last 6 months, and/or supporting verification documents are required.
Confidential Financial Statement
Nov 09, 2015
Confidential Financial Statement
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Applicant Information Provide your name exactly as it appears on your passport. Family/Last Name _________________________________ First Name _____________________________ Middle Name _______________________
Country of Citizenship ________________________ UCLA ID # _____________________________ Date of Birth ________________________ Month | Day | Year
Dependent(s) Information If Applicable Do Not Complete this Section if you do not have dependent(s) or will not be applying for F-2 or J-2 Visas for your dependent(s) at this time. If your dependent(s) will join you in the U.S. at a future time, you may request F-2 I-20s or J-2 DS-2019s for your dependent(s) from DCISS after your arrival to UCLA.
List your dependents who will be accompanying you to the U.S. on F-2 Visa status. Dependent(s) listed here will be issued certificate of eligibility(s) required to apply for F-2 or J-2 Visas from a U.S. Embassy or Consulate. Additional proof of financial support is required:
Spouse - $4,500 Children - $2,500 Per Child
[1] Dependents Name (as it appears on passport)_____________________________________________________________ Family/Last Name | First Name | Middle Name
Country of Birth _________________Citizenship __________________
Date of Birth _________________________________________________ Month | Day | Year
Relationship to Applicant ______________________________________
[2] Dependents Name (as it appears on passport)_____________________________________________________________ Family/Last Name | First Name | Middle Name
Country of Birth _________________Citizenship __________________
Date of Birth _________________________________________________ Month | Day | Year
Relationship to Applicant ______________________________________
[3] Dependents Name (as it appears on passport)_____________________________________________________________ Family/Last Name | First Name | Middle Name
Country of Birth _________________Citizenship __________________
Date of Birth _________________________________________________ Month | Day | Year
Relationship to Applicant ______________________________________
Source of Financial Support Please indicate your source(s) of funding as applicable. At least one source of funding must be indicated; not all sources of funding may apply to you.
Personal Funds Amount of personal funds as U.S. $ _______________ stated on your bank statement.
Name of Bank(s) ___________________________________________ [*Must submit valid personal bank statement, translated in English.]
Family or Individual Sponsors Funds
Sponsors Guarantee U.S. $ _______________
I _________________________________________, guarantee that the funds Please print full name
indicated here will be available for the applicant listed for tuition, fees and living expenses at UCLA. If the applicant will be attending UCLA Summer Sessions, the guarantee will also include Summer Session fees.
Signature of Sponsor _____________________________________________
Relationship to Applicant ___________________________________
Name of Sponsors Bank(s) __________________________________ [*Must submit sponsors valid bank statement, translated in English.]
UCLA Department Funds Amount to be Awarded U.S. $ ________________
Type of Award(s) ________________________________________ [*Must submit department funding letter or UCLA award/offer letter.]
Sponsoring Organization or Government Funds Amount to be Awarded U.S. $ ________________
Name(s) of Sponsoring Entity _______________________________ [*Must submit copy of the award letter issued from sponsoring entity specifying the amount and duration of funds.]
Total Financial Support U.S.$ ____________
Signature of Applicant: I hereby confirm the information indicated in this statement is true to the best of my knowledge and that I will havethe funds stated to attend UCLA. I understand that my enrollment at UCLA may be jeopardized if any information indicated here is found to be incomplete or false. I will notify UCLA immediately if there are any changes in my financial situation.
Signature of Applicant __________________________________________________________________ Date ________________________________
UCLADashewCenterforInternationalStudents&Scholars(DCISS) 106BradleyInternationalHall 417CharlesE.YoungDriveWest,LosAngeles,CA,9009513793108251681 internationalcenetr.ucla.edu
Confidential Financial Statement
This form must be completed and signed to verify evidence of financial support for the issuance of a UCLA I-20 or DS-2019. Signatures, bank statement(s) dated within the last 6 months, and/or supporting verification documents are required.
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First Name: Middle Name: UCLA ID: Relationship to Applicant_4: Type of Awards: Names of Sponsoring Entity: Date: Last Name: Citizenship: Month: Day: Year: D1Country of Birth: D1Citizenship: D1 Last Name: D1 First Name: D1 Middle Name: D2Country of Birth: D2Citizenship: D1Month: D1Day: D1Year: D2 Last Name: D2 First Name: D2 Middle Name: D3Country of Birth: D3Citizenship: D2Month: D2Day: D2Year: D3Month: D3Day: D3Year: D1Relationship: D2Relationship: D3Relationship: Personal Funds: Personal Bank: Family Funds: Family's Name: Sponors Bank: UCLA Funds: Other Funds: Total Funds: D3 Last Name: D3 First Name: D3 Middle Name:
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