PLEASE READ CAREFULLY. Return completed form to International Student
Affairs Office address at the bottom of page 2. Please circle surname/family
name. It should be the same surname/family name as on your passport.
Please type or print. Thank you.
Level of study:
Undergraduate Graduate Student ID (if assigned)
Please circle Surname/Family name. It should be the same Surname/Family name on your passport. Please type or print.Thank you.
1. Name:
(Family/Surname) (First/Given Name) (Middle Name) (Other names used)
2. Permanent home address:
(Number and street)
(Town or City) (Province or State) (Postal Code) (Country)
3. Mailing address:
(Number and street)
(Town or City) (Province or State) (Postal Code) (Country)
4. Telephone number: Fax number:
5. Email address: U.S. Social Security Number:
(If applicable)
Place of Birth:
6. Date of Birth:
(Month/Day/Year, i.e. January 21, 19##)
(City and Country)
7. Country of Citizenship: Country of Residence:
8. Are you currently studying on a U.S. Student Visa? Yes
No If yes, indicate current visa type I-94 number.
Visa type:
9. Name of
Parent Legal Guardian Other Relative
(Family/Surname) (First/Given Name)
Person in the US to whom Admission Status updates information and/or immigration documents may be released:
Name: Telephone number:
10. Sex: Male Female Marital Status: Single
Married Number of Dependents:
If you have any dependents who will come with you to the U.S. please list name, relationship, birth date and birth place for
each dependent. (You must show sufficient funds to cover your dependents’ living expenses while in the U.S. in addition to
your own funds. Refer to the Cost Estimate sheet. This is required for Visa application.)
(Family/Surname) (First/Given Name) (Date of Birth) (Country of Citizenship) (Country of Birth)
(Family/Surname) (First/Given Name) (Date of Birth) (Country of Citizenship) (Country of Birth)
(Family/Surname) (First/Given Name) (Date of Birth) (Country of Citizenship) (Country of Birth)
Refer to the Table of Cost Estimates and indicate the amount of money in U.S. dollars that will be available to you for all
years of attendance/degree. A Certificate of Eligibility (Form I-20) may only be issued when the student has been admitted
and shows satisfactory financial arrangements for meeting the expenses of his/her entire program of study at South
Dakota State University. See the appropriate cost estimate (graduate or undergraduate) for estimated costs of attendance
by education level. Funds for dependents accompanying you must also be included for the total years that you will be
studying. SDSU retains the right to require an advance deposit from students in countries that are experiencing difficulties
in foreign exchange. The I-134 will NOT be accepted by SDSU as financial certification.
11. Source and amount of funds in U.S. Dollars for each year of attendance/degree:
Self Support* $ Scholarship/Fellowship/Assistantship $
Sponsor/Family $ Describe relationship of sponsor:
Other $ Describe other source:
Total amount certified from sources above** $
* Self support students must show evidence of funding for the entire duration of the program (Not just one year.)
** The amount certified must equal or exceed the annual costs of attendance.
Refer to
12. Official Certification of Sponsor / Family
Please note: If your sponsor has completed AND signed a letter of financial support you do not need to have this part
completed. This is to certify that I have read the information furnished by the applicant on this form, that it is a true and accurate
statement, and that the funds are available and will continue to support the student for the duration of studies.
Name of Sponsor PLEASE PRINT Signature
13. I certify that the information provided here is correct and complete. (If sponsoring self, sponsor’s signature above is not necessary.)
Signature of prospective student:
Submit Financial Certification with an Original (Hard Copy) Bank Statement or Bank Letter with original signatures and
bank seal or stamp. The bank document must:
Clearly list the type of currency and amount of funds
Match the name of the signor on the Financial Certification
Have an issue date within 6 months of the receipt of the application
Written in English or provided with a certified translation
Please return this form and all undergraduate or graduate financial documents to:
Office of International Affairs
South Dakota State University
H.M. Briggs Library
Box 2115 - Briggs Library, Suite 119
1300 North Campus Drive
Brookings, SD 57007
South Dakota State University is an Affirmative Action/Equal Opportunity Employer (Female/Male) and offers all benefits, services, educational and employment
opportunities without regard for age, race color, religion, sex, disability, national origin, or Vietnam Era veterans. (4/13)
1-605-688-4122 phone | 1-605-688-6540 fax | e-mail
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