J-1 International Degree Student Financial Certification Form
The following information will be used to complete your J-1 visa documentation. Please complete and return this form by mail along with the identification and expiration page(s) of your passport, and the required proof of funding to the address below. Print clearly and legibly.
International Student and Scholar Services
University of Minnesota
190 Humphrey Ctr., 301 19th Ave. South
Minneapolis, MN 55455
Phone: (612)626-7100
Fax (612) 626-7361
1. Are you currently in the U.S.?
No – ISSS assumes you will use this DS-2019 to enter the U.S. If that is not the case, contact a J
adviser to discuss the situation. Go to # 2, if you checked “No”.
Yes – If yes, please complete items #1-3.
1. Copies of your current visa documents must be mailed or faxed to ISSS. Required copies
include I-94, entry visa (in passport) and DS-2019, I-20, or I-797.
2. Date of original entry to US: (month/day/year)
3. You are currently (Check a, b. c, or d)
a. on a J-1 visa and you are requesting a transfer to UMN J-1 sponsorship.
Please note that, if you have been approved by the Department of State for a waiver of the
2-year home residency requirement, you are not eligible for a transfer.
ISSS must follow SEVIS transfer procedures, including contacting the Responsible Officer at your
current school. Therefore, you must supply us with contact info for this person:
J-1 Responsible Officer at Current J-1 Program Sponsor: (Required):
Name: Phone #: Fax:
Institution: E-mail:
SEVIS Transfers: Under SEVIS, your current sponsor must approve the transfer and release you
to our program electronically in SEVIS before our office can issue a new DS-2019. Your current
sponsor indicates (in SEVIS) an effective date for the transfer. This is the date that you will start
the new program at UMN and that your transfer becomes effective.
However, ISSS will not be able to issue the new DS-2019 until the day your transfer becomes effective.
This means that we cannot issue your new DS-2019 before your arrival to the
U of MN. Also, the transfer must be processed by ISSS within 30 days after the effective date, at the
latest. This means that you need to come to ISSS to get your new DS-2019 no later than 30 days from
the effective date of your transfer.
b. on a J-1 visa in the same category but will leave and re-enter on a new UMN DS-2019 to begin a new program.
c. on a J-1 visa in a different category than requested in this application – You must leave
and reenter the U.S. on the new DS-2019. You should discuss the procedure with an ISSS
J-1 adviser.
d. on a different visa type. You must discuss the situation with an ISSS J-1 adviser before the
DS-2019 can be produced.
Name of the ISSS adviser contacted: ______
2. Which degree program have you been admitted to? ______Master Doctorate
3. What Term does your admission take effect? ______Year? ______
4. Will you receive Assistantship?
No --
____Yes -- If so, what percentage? ____ (If unsure, review your assistantship award letter).
5. Student ID Number (if known) ______
6. Name - Exactly as it appears on the passport. If no middle name, write (none)
Last: ______
First: ______
Middle: ______Suffix (e.g., Jr., Sr., I, II) optional: ______
7. Born ______in ______
MM DD YYYY City of Birth Country of Birth
8. Gender: ______
9. Current email: (Required field) Fax: Phone: ______
10. Current Address in Home Country:
Street: ______
City: ______
Country: ______Postal Code: ______
11. Country of citizenship: ______
12. Country of legal permanent residence: ______
13. Current Occupation in Home Country: ______
14 DEPENDENTS (IF APPLICABLE)
Do you wish to bring dependents on a J-2 visa? No (go to #14) Yes (fill out below)
(J-2 dependents are: Legal spouse and dependent children under 21. Do not include family members who are
U.S. citizens or were born in the U.S., they should use a U.S. passport to enter the U.S.)
____ J-2 dependents will be traveling with you to the U.S. (Please fill in dependent information below.)
____ J-2 Dependents will be traveling separately (Please fill in dependent information below)
Important: - J-2 dependents are not allowed to enter the U.S. before the J-1’s initial entry.
- Indicate name exactly as it is written in the dependent’s passport.
Dependent #1 PeopleSoft ID
Last Name
First Name
Middle Name
Date of Birth
Gender
Relationship to J-1 (spouse or child)
City of Birth
Country of Birth
Country of Citizenship
Country of PermanentResidence______
Dependent #2 PeopleSoft ID
Last Name
First Name
Middle Name
Date of Birth
Gender
Relationship to J-1 (spouse or child)
City of Birth
Country of Birth
Country of Citizenship
Country of Permanent Residence______
Dependent #3 PeopleSoft ID
Last Name
First Name
Middle Name
Date of Birth
Gender
Relationship to J-1 (spouse or child)
City of Birth
Country of Birth
Country of Citizenship
Country of Permanent Residence
15 EDUCATION EXPENSES
Tuition: Select the tuition amount which applies to your program. Note that students admitted to Architecture;
Landscape Architecture: Biological Science; Software Engineering; Manufacturing Systems Engineering; Public
Policy; Urban and Regional Planning; Science; Technology, and Environmental Policy, Public Affairs; Human
Resources and Industrial Relations; Geographic Information Science; and Management of Technology should use
those figures. Include Summer Session tuition only if you intend to register during the summer. The summer session
tuition indicated is approximately the cost of two courses.
Assistantship: A 25% assistantship provides a 50% tuition and health insurance reduction and the remaining at
resident rates; a 50% assistantship provides a 100% reduction of tuition and health insurance. An assistantship of
12.5% to 24% provides a tuition reduction only, with no waiver of non-resident tuition. The reduction is the amount
of resident tuition that is twice the percentage of your assistantship, deducted from your non-resident tuition
(e.g. a 14% time assistant, would deduct 28% of resident tuition from the required non-resident tuition). Please attach
a copy of your award letter to this form if possible. If you enroll for more than 14 credits per semester you will be
responsible for the additional tuition.
If you have a spouse who is currently holding a teaching or research assistantship at the University of Minnesota, you
are eligible to pay the resident rate tuition. Please submit with this form a photocopy of your marriage certificate and
a photocopy of a current payroll document showing your spouse’s assistantship.
Please note that J-2 income cannot be counted towards J-1’s source of funds.
If your spouse has J-1 or F-1 visa status and you wish to use any of your spouse’s assistantship salary to fund your
expenses, only the amount remaining after you spouse’s minimum expenses are subtracted may be applied towards
your own expenses.
Resident / Non-resident / Summer resident / Summer non-residentTuition rate for
6-14 credits / $9,302 / $16,400 / $4,651 / $8,200
Arch/Land Arch tuition for 12-17 credits / $15,064 / $25,484 / $7,532 / $12,742
Bio Sci per credit tuition / $1,169 per credit (6 credit minimum) / $1,169 per credit (6 credit minimum) / $1,169 per credit (6 credit minimum) / $1,169 per credit (6 credit minimum)
Bus Tax per credit tuition / $945 per credit (6 credit minimum) / $945 per credit (6-11 credits); $1,210 per credit (over 11 credits) / $945 per credit (6 credit minimum) / $945 per credit (6-11 credits); $1,210 per credit (over 11 credits)
Geo Inf Sci for
6-14 credits / $9,726 / $17,148 / $4,863 / $8,574
Human Res & Indust Rel (day) for 10-19 credits / $11,694 / $21,320 / $5,847 / $10,660
Human Res & Indust Rel (eve) per credit tuition / $680 per credit (6 credit minimum) / $990 per credit (6 credit minimum) / $680 per credit (6 credit minimum) / $990 per credit (6 credit minimum)
Infrastruct Syst Eng annual tuition / $11,400 / $11,400 / $5,700 / $5,700
Mgmt of Tech annual tuition / $26,800 / $26,800 / $13,400 / $13,400
Pub Policy, Urban & Regional Plan, Sci/ Tech/Environ Policy for 6-15 credits / $10,726 / $17,808 / $5,363 / $8,904
Pub Affairs per credit tuition / $894 per credit (6 credit minimum) / $1,484 per credit (6 credit minimum) / $894 per credit (6 credit minimum) / $1,484 per credit (6 credit minimum)
Software Eng annual tuition / $12,320 / $12,320 / $6,160 / $6,160
Tuition ______
Summer session/s tuition and fees (if applicable) ______
Books & supplies ($980 - $1,500) ______
Mandatory Student Fees & Health Insurance ($ 3,452) for non-assistants & 12.5-24% assistants ______
Mandatory Student Fees & Health Insurance ($ 2,563) for 25% assistants ______
Mandatory Student Fees ($ 1,226) for 50% assistants ______
TOTAL
You are required to specify the number of academic years covered by this Financial Certification and calculate the Education Expenses total amount.
Number of Years ______Education Expenses per year ______TOTAL
16 LIVING EXPENSES
These figures are estimates for living expenses for a 12-month period. If your projected cost of living is $13,000, you should plan for a lifestyle that includes shared lodging, modest meals, and few amenities. If you receive free room and board from a sponsor, you should indicate here the cost your sponsor incurs on your behalf and list your sponsor as a resource for that amount.
You are required to specify an amount between the range of $ 13,000 - $ 25,000 for each 12-month period.
TOTAL
17 DEPENDENT EXPENSES (IF APPLICABLE)
Dependents cannot be included on your visa form unless you show that you have sufficient funds to cover their personal maintenance expenses. If you wish your dependents to travel with you, please complete the section below. Please that a substantial portion of the amount shown is for dependent health insurance coverage.
# of Dependents Required funding for Dependents
1 $642/month (x 12 months = $7704)
2 $902/month (x 12 months = $10824)
3 $1,110/month (x 12 months = $12120)
4 $1,323/month (x 12 months = $ 14676)
5 $1,530/month (x 12 months = $17160)
# of dependents: x $ TOTAL
This estimate does not include the cost of clothing, automobile expenses, long distance travel, and other items not required to meet basic needs.
Add the figures in the boxes to find your total expenses GRAND TOTAL
18 SOURCE OF SUPPORT
List the amount in U.S. dollars available to you to study at the University of Minnesota. The amount should cover the total number of academic years you want this Financial Certification to cover.
UMN FundingPlease attach documentation verifying UMN funding (gross amount). Please be aware that most likely the amount of your assistantship is a gross amount and it includes taxes. After deducting the taxes, the actual net amount you will be receiving will be approximately 30% less.
First Year
/Second Year
(if applicable) / Third Year(if applicable) / Total
(Please fill out)
q Teaching/Research Assistantship
# of month ______
% of appointment ______/ $ / $ / $ / $
UMN Funding Total /
$
/ $ / $ / $Other Funds
Please attach documentation verifying non-UMN funding. To be considered, it must be written in English and in US currency. Use the first four categories below only if you received the funds directly.
First Year / Second Year
(if applicable) / Third Year
(if applicable) / Total
(Please fill out)
q U.S. government agency / $ / $ / $ / $
Name:
q International organization / $ / $ / $ / $
Name:
q Exchange visitor’s government / $ / $ / $ / $
q The binational commission of the exchange visitor’s country / $ / $ / $ / $
q All other universities or organizations providing support / $ / $ / $ / $
Name:
q Personal funds/Family / $ / $ / $ / $
Other Funds Total / $ / $ / $ / $
19 CERTIFICATION BY STUDENT
I certify that the statements given by me on this form are complete and accurate. Furthermore, I will take financial responsibility for all my educational and personal expenses should my source of funding, as specified above, be interrupted or stopped. I understand that the University of Minnesota accepts no responsibility for my financial needs, and if bringing my dependents, I understand that I am also financially responsible for them and must provide them with health and hospitalization insurance coverage during their entire stay in the U.S. I understand that I can be required to show proof of health insurance coverage for 12 full months. Health insurance can be purchased at the time of registration.
Signature of Student (Required) ______Date ______
1 / INTERNATIONAL STUDENT & SCHOLAR SERVICES, U of MN190 Humphrey Center, 301-19th Ave. South
Minneapolis, MN 55455, U.S.A.
www.isss.umn.edu
Updated by ACB 01/1/2007