Do you plan to enter the U.S. from abroad? No Yes
Do you currently hold a U.S. visa? No Yes If yes, type of visa:_________________
Name of school that issued your last I-20 or DS-2019:___________________________________________________
If in the U.S., give your SEVIS I.D. number:_____________________________________________________________
If you plan to bring dependents, list their names and birthdates in the space below. Provide evidence that approximately
$4,000 per year/per dependent is available above the amount required for yourself:
Name SEVIS I.D. # Birthdate Country of Birth Country of Citizenship Relationship Gender
_______________________________________________________________________
Address:________________________________________________________________________________________________
Name of account holder:__________________________________________________________________________________
Type of account: savings certificate of deposit other___________
Date account opened: Month__________ Day_______________ Year________________
Confirmed by bank employee:
Name:___________________________Title:__________________________________________
Signature:_________________________________________________ Date:_