Updated: February 6, 2014

ATTACHMENT B

California State University Northridge

DEPENDENT REQUEST FORM – ADD, REMOVE OR EXTEND J-2 DEPENDENT

Section 1: Information about J-1 Scholar (Please Print)

Last Name (Family Name):

First Name:

Middle Name:

Male: Female:

Birth date (month/day/year):

SEVIS ID Number:

Email Address:

Phone Number:

I request that the dependent(s) named below be added to my SEVIS record.

I request that the dependent(s) named below be removed from my SEVIS record.

Please explain:

I have notified the dependent(s) named that he/she/they will be removed from my SEVIS record.

I have NOT notified the dependent(s) named that he/she/they will be removed from my SEVIS record.

I request that the dependent(s) named below be extended in my SEVIS record.

I understand that I will need to purchase insurance for my dependent (s) for the duration of my program.

______
Scholar’s SignatureDate (mm/dd/yyyy)

Section 2: Information about J-2 Dependents(s) – Copy(ies) of Passport Photo(s)MUST be included

Dependent 1 / Dependent 2 / Dependent 3
Last/Family Name (as it appears in passport)
First/Given Name
Middle Name
Gender
Relationship to you
Date of Birth (mm/dd/yyyy)
City of Birth
Country of Birth
Country of Citizenship
Country of Permanent Residence

Section 3: Source of Funding (please provide sufficient financial documentation):

CSUN is required to document proof of financial responsibility for visiting scholars and their dependents. Each visiting scholar must show ability to support visiting dependents (approximately $750 per month/per family member is required).

Please indicate below the source of this funding.

Funding Source / Please
Check
CSUN General Fund
Account # ______
The University Corp
Account # ______
U.S. Government agency funds to this Exchange Visitors:
Name of Agency: ______
International Organization: [e.g. UN, WHO, NATO] funds to this Exchange Visitor: Name of Agency:______
Exchange Visitor’s Government:
Name of Agency: ______
Other organizations/Institutions in the U.S. or abroad:
Names(s): ______
Personal funds (include bank statement):

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Updated: February 6, 2014

3B – BENEFITS: As part of resource allocation, what type of benefits do you intend to provide?

No Benefits - for employees who work less than 29 hours a week and/or have an appointment of less than 3 months

Benefit Category Group A –for salaried employees working an average of 20 or more hours a week

-Vacation-Paid Holidays

-Sick Leave-Retirement Benefits (under specific conditions)

-Personal Holiday-Tax Sheltered Annuity Plan

Benefit Category Group B -for employees working an average of 30 or more hours a week

-Vacation-Dental Plan

-Sick Leave-Vision Plan

-Personal Holiday-Life Insurance/AD&D

-Paid Holidays-Retirement Benefits (under specific conditions)

-Health Insurance-Tax Sheltered Annuity Plan

3C – HEALTH CARE COVERAGE: Proof of health insurance (including provisions for evacuation and repatriation) is required for the research period. If the visiting scholar wishes, this insurance can be secured through CSUN prior to arriving in the U.S. If secured elsewhere, please provide evidence of coverage. (i.e., submit a copy of policy provisions).

3D -- HOUSING: While the sponsoring college/department may not be providing housing for the visiting scholar (who may, for example, have those arrangements covered by their home institution, by personal funds, or the like), it is important that the sponsoring CSUN department/college check to ensure that housing arrangements are in place (so that the visiting scholar does not arrive with mistaken expectations and/or no housing arrangements in place).

3E – REVIEW CONFIRMATION

The signature of the sponsoring college MAR indicatesthat all elements of Section 3 above have been reviewed.

Signature of the College MAR: ______Date: ______

3F – Human Resources Approval from the CSUN University Corporation:

Print Name: ______

Title: ______

Signature: Date: ______

______

3G -- Budget Verification from the CSUN University Corporation if the planned visit will use CSUN grant funds managed by the CSUN University Corporation:

The signature of the University Corporation representative, below, confirms that the grant funds as proposed in the budget above are available and are being appropriately used for the proposed scholarly visit as outlined in sections 1 and 2 above

Print Name:______

Title: ______

Signature: Date:______

Section 4: Signatures

FACULTY AFFAIRS: The signature of the Interim Associate Vice President for Faculty Affairs confirms that this form has been completed in keeping with University procedures and provides the information necessary to approve the request and process a formal letter of invitation.

Print Name ______

Signature: ______Date: ______

CSUN PROVOST: The signature of the Provost (or designee) indicates that the Provost has been informed of this planned visit and supports its moving forward as described above.

Signature: ______Date: ______

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