Ealing Hounslow Merton Hillingdon Lambeth Wandsworth

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
UTD ID
Date of Birth
A. Select the reason for submitting the Financial Affidavit. F-1 students must provide evidence of financial support for one
academic year in order to receive the types of I-20’s listed below.
Request Initial I-20:
Update Current I-20:
⃝ Update financial information on I-20
⃝ To enter the US
⃝ Self
⃝ with Dependents (submit the UT Dallas Financial
Affidavit for F-2 Dependents)
⃝ To Transfer In to UT Dallas from another US Institution ⃝ To apply for a Change of Status to F-1 ⃝ Change of Level Request ⃝ Program Extension request ⃝ Add/update dependent information ⃝ To apply for Reinstatement to F-1 Status (submit the UT Dallas Financial Affidavit for F-2 Dependents) 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 http://www.utdallas.edu/isso/UTDAward/
⃝ 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 UT Dallas Financial Affidavit. If you have more than three sponsors, please include an page 1 of additional financial affidavit.
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/ revised 07/07/2014
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.
Official Bank Stamp or Seal (Required)
Name of bank:
Address of bank:
Name of account holder(s):
Last four digits of account
number(s):
Amount available in US
Dollars:
Bank official’s name
(PRINT):
Bank official’s title:
Date:
Bank official’s signature:
F. Determine your estimated expenses. Below is a list of the estimated annual costs of attendance, living expenses (based on
shared housing and use of public transportation), and health insurance. You must provide financial certification of these minimum
amounts as a part of the I-20 request process. These estimates are subject to change without prior notice; the exact costs of
attendance will vary by student and will be determined at the point of course registration. For dependents: Please see page 3.You
will need to add $5000 for your spouse and $3000 for each child, per year plus the cost of health insurance.
Undergraduate students
Tuition, 12 credit hours per semester
Living Expenses
Health Insurance
Total
General
$27,104
$14,262
$1,859
$43,225
Graduate students
General
Tuition, 9 credit hours per semester
Living Expenses
Health Insurance
Total
$22,502
$14,464
$1,859
$38,825
With UT Dallas Scholarship
$11,079
$14,262
$1,859
27,200
With UT Dallas Research or Teaching
Assistantship, or Scholarship
$12,152
$14,464
$1,859
$28,475
*If your situation differs what is listed above, visit the ISSO Estimate expenses for I-20 webpage at http://www.utdallas.edu/isso/i20expenses/
G. Submit to the ISSO
 Your UTD 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 e-mail (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/ revised 07/07/2014
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
UTD ID
Date of Birth
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 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 or engage in full 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:
I.
Date:
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
(Spouse or
Child)
Gender
(M or F)
Family Name/Surname
Given Name
Date of Birth
(mm/dd/yy)
Country of
Birth
Country of
Citizenship
⃝ Add ⃝ Remove
⃝ Add ⃝ Remove
⃝ Add ⃝ Remove
J. Estimated expenses for you and your dependents. *If your situation differs what is listed, visit the ISSO Estimate expenses for I20 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
$14,262 Plus$5000 for spouse and/or $3000 for each child
Health Insurance
$1,859 (Student only) OR
$7,125 (Student and Spouse) OR
$10,019 (Student, Spouse and Children)
Graduate students
General
With UT Dallas Research or Teaching
Assistantship, or Scholarship
Tuition, 9 credit hours per semester
$22,502
$12,152
Living Expenses
$14,464 Plus $5000 for spouse and/or $3000 for each child
Health Insurance
$1,859 (Student only) OR
$7,125 (Student and Spouse) OR
$10,019 (Student, Spouse and Children)
UT Dallas / International Student Services / FinAff/ revised 07/07/2014
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