Fillable Financialstatementofresponsibility

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Financialstatementofresponsibility

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File type: PDF

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Financial Statement of Responsibility
This form is for a F1 or F3 applicant who are required to demonstrate the ability to cover all expenses while attending Eastern Michigan
University.
PART 1: Applicant ( Enter name as shown on passport & include copy of passport with this form)
Surname/Last First Name Middle Initial EMU ID
Applicant's Home Country Address
City Province/Region Country Postal Code
Email Phone
Current immigration/VISA status (select one): Gender Marital Status
Date of Birth (mm/dd/yyy)
Birth Country
Birth City
Country of Citizenship
Expected VISA Type
(select one)
Term
Program of
Study
Bringing Spouse or Children
Total number of dependents
If bringing dependents, include copy of each passport & complete the information below:
Last Name First Name
Relationship to
Applicant
Date of Birth Birth Country
Country of
Citizenship
SEVIS number?
Do you plan to travel abroad prior to beginning at EMU?
If so, indicate the travel dates:
Select how you will receive your I-20:
I will pay for shipping using University Express Mail Services (UEMS) eshipGlobal.
I will pick up my I-20 in person from 244 Student Center, Ypsilanti, MI, 48197
Eastern Michigan University offers you the opportunity use an express mailing service that will allow you to receive the documents through DHL, FedEx, or UPS in
three to five days. Requesting your documents through express mail is at your expense, and your credit card (Visa, Mastercard or Discover cards only) will be charged
upon requesting the service. To learn more visit http://www.emich.edu/admissions/requirements/I20_handling.php
Part II: Select your estimated costs: The dollar figures in the plans below include costs for tuition & fees, transportation, books,
room & board, and mandatory health insurance. Costs are for one academic year using current school year rates. Totals are
shown in United States Dollars (USD) for minimum full time enrollment. (Place an “X” next to your selection)
Plan 1
F-1 or J-1 VISA Applicants
(full - time enrollment)
Fall & Winter
Plan 2
F-3 VISA Canadian Commuters
(part-time Enrollment
Fall & Winter
F1/J1 Graduate $31,354 F3 Graduate $16,555
FJ/J1 Undergraduate $36,031 F3 Undergraduate $18,893
Fill in the top box on right side with correct amount from above. If
bringing dependents add additional from below.
- Health insurance (optional) spouse: $5,750
- Health insurance (optional) per child: $2,834
- Living expenses for each addl. family member: $6,325
$
Total Optional HI $
Total Living $
Total USD for I-20
Eligibility $
Date (MM/DD/YYYY)
Confirmation of Electronic Signature Agreement: By checking the referenced box you are signing this document electronically.
Your agree your electronic signature is the legal equivalent of your manual signature on this document and recognize that you are
legally bound by the provided information.
Type applicant surname/last name / first name
International applicants must submit an official bank statement with original/live signatures providing proof of liquid funds equal
to or exceeding the “Total USD for I-20 Eligibility” above. The bank statement can be mailed to the address below or dropped off in
person in the International Admissions Office, 220 EMU Student Center. NO FAXES, SCANS, or PHOTOCOPIES of bank statements
will be accepted.
If the name on the bank statement is NOT the applicant please have sponsor fill out the Financial Affidavit of Support.
MAILING ADDRESS FOR ALL FINANCIAL DOCUMENTS:
International Admissions
Eastern Michigan University
401 Pierce Hall
Ypsilanti, MI 48197 USA
Document can be printed and scanned for email submission. Documents should be emailed to international_admissions@emich.edu
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Financialstatementofresponsibility

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Completed 29 January 2020

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