Fillable Printable Affidavit of Financial Support Form - Houston Community College System

Affidavit of Financial Support Form - Houston Community College System

3100 Main Street, MC1138, Hous ton, TX 7700 2 T713.718. 8521 F 713.718. 2112 W hccs.edu

Rev.05/2013

This is to certify that I will assume financial responsibility for thestuden t’s durat ionof study at Houston

Comm un ity Colleg e (and depe nd ents, if ap pl ic able).

Full Financial Responsibility* [ ] Tuition and Fee Expenses* [ ] Living Expenses* [ ]Dependent Expenses**[ ]

NOTE: *

You must include additional supporting financial documents showing assets in the amount of $22,980USD

(given this is the estimated cost for a full year of study at HCC). **Additionalfinancial support required: $4,400USD

per dependent.These figures are subject to change without notification.

STUDEN T INF O RMATION :

___________________________ _______________ _______________________________________

Family (Last) NameFirst NameDat e o f Birth

DEPENDENT INFORMATION:

(Copy of proof of relationship must be submittedin English. Additional

dependents can be added on a separate sheet of paper.)

_________________________________________________________________________________

Family (Last)NameFirst NameDate of Birth

_________________________________________________________________________________

Country of Birth Country of Citizenship Relationship

FINANCIAL SPONS OR INFORMATION:

_________________________________________________________________________________

Family (Last)NameFirst N a meDate of Birth

_________________________________________________________________________________

Relationsh ip to St ud entEmailTelephon e num ber

___________________________________________________________________________________________________

Sponsor’s CompleteMailing Address

I acknowledgethat t h e above financ ial support inform ation is ac curate and com plete to t he

best of my knowledge.I am aw are of my financial res po n sibilitie s as a f inancial sponsor to t he

student named on this form. I therefore certify that I know the contents of this affidavit signed by

me and that the content is true and correct.

______________________________ _________________________

Financial Sponsor’s SignatureDate of Signature

Affi da vi t of Financial Support

(For Non-US Citize n/ Non-US Resident Sponsor)

HCC ID: ___________________