Fillable Printable Affidavit of Financial Support Form - Michigan

Affidavit of Financial Support Form - Michigan

Affidavit of Financial Support

For ELP, Undergraduate, Graduate, and Exchange Students

For what program are you applying?

English Lan guage Progr am

Undergraduate

Graduate

Exchange

APPLICANT’ S PE RS O NALINFORMATION

Instructions: Please read this information carefully. Failure to follow instructions may result in a delay in processing your immigration document. You are required to

certify t he availabi l ity of fund s to c o ver the estimated expenses (notincluding d ependents) for the firs t year. Please see sheet two f o r estimated expen ses f o r

particular programs.

Last Name (Family Name)

GenderMaleFemale

First Name (Given Name)

Date of Birth (month/day/year)

City and Country of Birth

Countryof Citizenship

Coun t ry of Leg al Perman en t Residence

Major

Current Occupation

Proposed Term of Admission

E-mail Address

UMID Number (if known, 8 dig its)

If currently in the U.S., indicate visa type: ________. If you currently have an F-1 or J -1 vi sa, you must attach a copy of your mo st r ecent I-20 or DS-20 1 9, passpo r t,

I-94 c ard, and visa. Fai lure to provide a c opy will delay the proc es s ing of your i m m igration document.

PL EASE PROVIDE THE MAILING ADDRESS WHERE YOU WOULD LIKE TO RECE I VE YOUR IMMIG RATION DOCUM ENT. PLEASE P RINT

CLEARLY.

Name:

Address:

City

Country

PostalCode

Telephone

Documentation of Funds

Co mp l ete thi s form andprovide all documen tatio n as requi red. Please note:

•Of ficial a n d orig i na l d a ted document smust be provided. Phot oc op i es an d faxed do cu ments are NOT ac cep table. All documents must be in English;

translations must be signed and sealed by the appropriate government or bank official.

•All supporting documentation must be dated within one year of initial enrollment (si x m onths i f the spon s or is living in the U.S. ) .

Personal Funds

•Com plete t he Affid avit of Financial Support and submit an officia l datedbank statement for each individu al c ont ributing financially to your education. In

case of jointly held accounts, ea ch individual h older must complete th e s ponsor section.

•Together, all funds must equate thet ot al es timated expen sesf or each semest er of study

•If y our spo ns o r is a Permanent Resident o r ci tizen o f th e U .S., a comp l eted I-1 34 form, includ ing an off icial b ank statement,is required. Form I-134 is

available at:http://www.uscis.gov/files/form/I-134.pdf

Gove rnment/ Emplo yer/Organization Funds

•Submit a detailed letter from the sponsor indicating the exact dollar amount for tuition/fees, living expenses, books and supplies, and health insurance.

•The letter must includ e the field of study an d dates of sp onsors hip.

Page 1 of 3 I:\Forms\IC Forms \Sunapsis-Test\Affidavit_of_Financial_Support.docxrev 6/14

219 University Center 303 E. K e a rs l eyFlint MI 48502 810-762-0867fax 810-762-0006 ic@umflint.edu

www.umflint.edu/international

Affidavit of Financial Support

For ELP, Undergraduate, Graduate, and Exchange Students

Estimated Expenses Worksheet

UNDERGRADUATE P RO G RAMS

UNDERGRADUATE

PROGRAM

Estimate d Student Expense s

(September – April)

Estimated Dependent Expenses

(12 month)

Tuiti on an d Fees

$18,372

Spouses living expenses, not including health

insurance

$5,000

Livi ng Expens es

$9,210

Each additional dependent’s living expenses

$2,700

Health Insurance

$1,401

Mandatory health insurance for one dependent

$5,121

Books and Su pplies

$750

Mandatory healt h insu r ance for mor e than one

dependent (family coverage)

$8,850

M iscel laneous E x penses

$900

Total Estimated Expenses*

*Subject to ch ange

$30,633

GRADUATE PROG RAMS

GRADUATE PROG RAM

Estimate d Student Expense s

(September – April)

Estimated Dependent Expenses (12 month)

Tuiti on an d Fees

$12,336

Spouses living expenses, not including health

insurance

$5,000

Livi ng Expens es

$9,210

Eachadditional dependent’s living expenses

$2,700

Health Insurance

$1,401

Mandatory health insurance for one dependent

$5,121

Books and Su pplies

$750

Mandatory healt h insu r ance for mor e than one

dependent (family coverage)

$8,850

Miscellaneous Expenses

$900

Total Estimated Expenses*

*Subject to ch ange

$24,597

ENGLISH LANGUAGE PROGRAM

ENGLISH LANGUAGE

PROGRAM

Estimate d Student Expense s

(September – April)

Estimate d Student Expense s

(May-July)

Estimated Dependent Expenses (12 month)

Tuiti on an d Fees

$11,000

Tuiti on an d Fees

$5,500

Spouses living expenses, not including health

insurance

$5,000

Livi ng Expens es

$9,210

Livi ng Expens es

$4,605

Each additional dependent’s living expenses

$2,700

Health Insurance

$1,401

Health Insurance

$701

Mandatory health insurance for one dependent

$5,121

M iscel laneous E x penses

$700

M iscel laneous E x penses

$350

Mandatory healt h insu r ance for mor e than one

dependent (family coverage)

$8,850

Total Estimated Expenses*

*Su b ject to change

$22,311

Total Estimated

Expenses*

*Subject to ch ange

$11,156

EXCHANGE PROGRAM

EXCHANGE

PROGRAM

Estimate d Student Expense s

(One Semester Fall OR Winter)

Estimate d Student Expense s

(Two Semester – Fall AND Win ter )

Livi ng Expens es

$4,605

Livi ng Expens es

$9,210

Health Insurance

$701

Health Insurance

$1,401

Books and Su pplies

$375

Books and Su pplies

$750

Transportation

$200

Transportation

$400

M iscel laneous E x penses

$450

M iscel laneous E x penses

$900

Total Estimated Expenses*

*Subject to ch ange

$6,331

Total Estimated

Expenses*

*Subject to ch ange

$12,661

Transportation costs to and from the U.S. are not included. In addition to the above estimated costs, allowances must be made for edu catio n al and relat ed expenses .

Estimates for tuition, books, living expenses, and miscellaneous expenses for optional Spring a n d S um m er ter m s ar enot i n clude d. Health i ns ura nce is r equi red for

a ll F-1 and J-1 visa students and their dependents. Stude nts are auto matically e nrolle d in the univer s ity po li cy at the ir own expe nse. Students who ha ve a

comparable policy or purchase one can request to opt out of the university plan by completing a waiver form.

Page 2 of 3 I:\Forms\IC Forms \Sunapsis-Test\Affidavit_of_Financial_Support.docxrev 6/14

219 University Center 303 E. K e a rs l eyFlint MI 48502 810-762-0867fax 810-762-0006 ic@umflint.edu

www.umflint.edu/international

Affidavit of Financial Support

For ELP, Undergraduate, Graduate, and Exchange Students

Sponso r (s) Section

FIRSTSPONSOR

Nam e of Spon sor (plea se print) _______________ ____________ ______ ____ Relation shi p to Student ______________ ______ __

Address of Spon s or ___________ _______ ______ ____________ ______ ______ ______ ____________ ______ ______ ___________

Iwill provide (check one): __ _ full financial support ___ partial financial supportin th e amount of $________ ____ per year for the applicant’ s ( anddependent s ,

i f applicabl e) tuit ion, fees, and living expenses for the en tire lengt h of study at the Univ ersity of Michi g an-Flint. As verificationthat funding is available, I h ave

attached an original bank statement(s) or letter(s). (Please indicate applicant’s name on all financial documents.)

Si gnature of spo n so r ___________ _____ ____________ ______ _Date ______________________________________

SECOND SPONSOR (ifa ppli ca ble )

Nam e of Spon s or (pleas e print) ____________ ______ ______ ____________ _ Relationship to Student ____________________ __

Addr es s of Spon sor _______________ ______ ______ ______ ____________ ______ ______ ______ ____________ ______ ________

I will p rovide p artial financial supportin the amount of $____________ per year for the applicant’s (and dependents, if applicable) tuition, fees, and living expenses

for the entire length of study at th e University of Michigan-Flint. As verification that funding is available, I have attached an original bank statement(s) or letter(s ) .

(Please indicat e ap plica nt’sna me on all fina ncial d o cum ents .)

Si gnature of spo n so r ___________ _____ ____________ ______ _Date ______________________________________

APPLICANT SECTION

NOTE: Dependen ts can only be a spouse or child. You must submit copies of each dependents passport to make their immigration documents (I-20/DS-2019)

Dependent Informa tion (if applica ble )

Dependent Name

Relationship To You

Birth Date (MM/DD/YYYY)

City, Country of Birth

Countr y of Citizenshiip

REQUIRED

Appli ca nt De clara tion:I, ____________ ______ ______ ____ h ereby promi s e that th e informa tion provid edis correct andc om plete.

(Appli cant’ s printe d na me)

I understand Iultimately am responsible for all anticipated yearly expenses for the length of my stay at the University of Michigan-Flint. I und erstandthat these

documents will not be returned to me.

Si gnature ____________________ _____ ____________ ______ _Date _______________________________________________

Please m ail the c ompleted Affidavit of Financial Support form in an envelope to:

International Center

University of Michigan-Flint

219 University Center

303 E. Kearsley St.

Flint, MI 48502-1950

U.S.A.

Page 3 of 3 I:\Forms\IC Forms \Sunapsis-Test\Affidavit_of_Financial_Support.docxrev 6/14

219 University Center 303 E. K e a rs l eyFlint MI 48502 810-762-0867fax 810-762-0006 ic@umflint.edu