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UT Dallas/International Student Services/FinAff/Updated 062315
THE UNIVERSITY OF TEXAS AT DALLAS International Student Services
800 W. Campbell Rd., SSB34, Richardson, Texas 75080-3021 (972) 883-4189 [email protected]
UT Dallas Financial Affidavit for F-1 Students
Student Name: Date of Birth:
Email Address: UTD ID:
A. Select the reason for submitting the Financial Affidavit. F-1 students must provide evidence of financial support for one academic yearin order to receive the types of I-20’s listed below.
Request Initial I-20: Update Current I-20: To enter the US: Add/Update dependent information
Self With Dependents (submit the UT Dallas (Submit the UT Dallas Financial Affidavit for F-2 Dependents)
Financial Affidavit for F-2 Dependents)
Transfer in to UT Dallas from another US Institution Update Financial Information on I-20 To apply for a Change of Status to F-1 Status Change of Level Request
To apply for Reinstatement to F-1 Status Program Extension Request
Other:
B. Student Financial Certification (handwritten signature required).
I certify that the amount of funds indicated in the bank certification section on this form, or in any submitted financial statements or letters, are available for my academic study at The University of Texas at Dallas. Additionally, I have sufficient funding to support each year of my education at UT Dallas, including funds for my spouse and children, if applicable.
Student Signature: Date:
C. Select the source of your financial support. (select all that apply)
Self. Submit financial documents which list your name as the account holder. Sponsors. Submit financial documents which list account holder(s) as your spouse, parents, family or other individuals.
UT Dallas Assistantship, Scholarship or Financial Award. Submit a copy of your award letter OR Assistantship Affidavit form.
A Business or Government. Submit letter on letterhead.
Other. Please indicate your source of funding:
D. Sponsor Financial Certification (only required if you have sponsors). ALL named account holders must sign and certify the UTDallas Financial Affidavit. If you have more than three sponsors, please include another page one of the financial affidavit with the additionalsponsors.
I certify that I am willing and able to financially support the student named on this form for the amount indicated in the bank certification section on this form, or in the attached bank statement or letter, for every year of their study at UT Dallas.
Sponsor #1 Name:
Sponsor Signature: Date:
Sponsor #2 Name:
Sponsor Signature: Date:
Sponsor #3 Name:
Sponsor Signature: Date:
UT Dallas/International Student Services/FinAff/Updated 062315
E. Bank Certification (optional). Either have your bank complete this section OR attach a supplemental funding document.
I certify that the student or the sponsor named on this form has full access to the funds described in this section. Further, I certify that the funds described in this section can be withdrawn at any time, are liquid, and can be used without restriction to sponsor the education of the above named student while in the United States. This certification is given for the student’s educational purpose in the United States and does not hold the bank responsible or liable.
Name of Bank:
Address of Bank:
Name of Account Holder:
Last 4 Digits of Acct. #:
Available Amount in US Dollars:
Bank Official’s Name (PRINT):
Bank Official’s Title:
Bank Official’s Signature: Date:
F. Determine your estimated expenses. Below is a list of the estimated annual costs of attendance, living expenses (based on sharedhousing and use of public transportation), and health insurance. You must provide financial certification of these minimum amounts as a part ofthe I-20 request process. These estimates are subject to change without prior notice; the exact costs of attendance will vary by student and willbe determined at the point of course registration. For dependents: Please see page 3.You will need to add $5000 for your spouse and $3000for each child, per year plus the cost of health insurance.
Undergraduate Students General With UT Dallas Scholarship
Tuition, 12 Credit Hours per Semester $27,104 $11,079
Living Expenses $14,664 $14,664
Health Insurance $2,182 $2,182
Total $43,950 $27,925
Graduate Students General With UT Dallas Research or Teaching Assistantship, or Scholarship
Tuition, 9 Credit Hours per Semester $22,504 $12,154
Living Expenses $14,464 $14,464
Health Insurance $2,182 $2,182
Total $39,150 $28,800
G. Submit to the ISSO• Your UT Dallas Financial Affidavit• Supplemental financial support documents, if applicable
Examples of financial support documents include: Copy of bank statement, scholarship letter, UT Dallas assistantship letter or government funding support letter. All supplemental funding documents must meet the requirements listed on the UT Dallas website at: http://www.utdallas.edu/isso/i20-docs/. This form is valid for 6 months from the date of the earliest signature. An e-mail will be sent to your utdallas.edu email address to notify you on the status of your I-20.
• In Person: Submit to the ISSO during office hours. Monday - Thursday, 8:30am to 6pm. Friday, 8:30am to 5pm.• By Email: (additional paper copies are not required): Submit to [email protected]. Verify that the total size of
attachments in one e-mail is not larger than 5MB. Do not send files in compressed formats, such as .rar or .zip. Instead,use a PDF, JPEG or DOC format.
UT Dallas/International Student Services/FinAff/Updated 062315
THE UNIVERSITY OF TEXAS AT DALLAS International Student Services
800 W. Campbell Rd., SSB34, Richardson, Texas 75080-3021 (972) 883-4189 [email protected]
UT Dallas Financial Affidavit for F-2 Dependents Student Name: Date of Birth:
Email Address: UTD ID:
H. Select the F-2 action requested. This form is only required if you have dependents coming to or remaining in the U.S.
Add or Maintain Dependent(s) to F-1 Record
Student Certification (Handwritten signature required). By signing below, I request the creation/maintenance of the F-2 SEVIS records for my spouse and/or child. I understand that dependents in F-2 status are permitted to stay in the United States only to the extent that the F-1 student is authorized to stay. F-2 spouses may not work and may only engage in part time study, and F-2 children may only engage in full time study in elementary or secondary school.
Student Signature: Date:
Remove Dependent(s) from F-1 Record
Student Certification (handwritten signature required). I certify that by signing below, I request that my dependent(s) SEVIS record(s) be terminated. I understand that the I-20 my dependent holds is no longer valid for purposes of entering or remaining in the U.S.
Student Signature: Date:
I. Dependent Information. If you are adding or removing your dependents from your SEVIS record, fill out their information below.If possible, please submit a copy of your dependent’s passports.
Add or Remove Relationship Gender Family Name/Surname Given Name Date of Birth
(mm/dd/yyyy) Country of Birth
Country of Citizenship
Add Remove
Spouse Child
Male Female
Add Remove
Child Male Female
Add Remove
Child Male Female
Add Remove
Child Male Female
J. Estimated expenses for you and your dependents. If your situation differs from what is listed, visit the ISSO Estimatedexpenses for I-20 webpage at http://www.utdallas.edu/isso/i20-expenses.
Undergraduate Students General With UT Dallas Scholarship Tuition, 12 Credit Hours per Semester $27,104 $11,079
Living Expenses $14,664 Plus $5,000 for spouse and/or $3,000 for each child
Health Insurance
$2,182 (Student Only) OR
$8,321 (Student and Spouse) OR
$11,705 (Student, Spouse and Children)
Graduate Students General With UT Dallas Research/Teaching Assistantship, or Scholarship
Tuition, 9 Credit Hours per Semester $22,504 $12,154
Living Expenses $14,464 Plus $5,000 for spouse and/or $3,000 for each child
Health Insurance
$2,182 (Student Only) OR
$8,321(Student and Spouse) OR
$11,705 (Student, Spouse and Children)
