Fillable Form 125-067B: No I Northern Virginia ~IA 'WN (Northern Virginia Community College)

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Form 125-067B: No I Northern Virginia ~IA 'WN (Northern Virginia Community College)

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No
~IA
I Northern Virginia
'WN
Community College
Form 125-067B
Rev. 1/20
Page 1 of 2
F-1 Student Financial Statement – Intensive English Program
Instructions: As a student, it is your responsibility to demonstrate that you will have sufficient financial support available to cover all
educational and living expenses while you are studying at NOVA. You must show a promise of funds and you must provide bank statements to
show that the promised money is presently in a bank.
Please make a copy of all financial documents before sending them to NOVA. You will need copies of these documents when you apply for
your F-1 visa status.
All bank statements must be in English or a certified English translation showing the account owner’s name, statement date, balance and
type of currency. (NOVA reserves the right to request clarification or additional information related to bank statements)
Estimated Academic Year Cost
Tuition
Living Expenses (housing, food, etc)
Books and supplies
Total
$ 6,740
$ 13,311
$ 1,200
$ 21,251
Tuition: R
ates are subject to change without notice. Tuition amount is based on the equivalent of 12 credits per semester. IEP courses are
offered as Continuing Education Units (CEUs) which are non-credit courses.
Housing: NOVA does not offer housing. You will be responsible for making your own living arrangements. Living expenses are estimated.
Dependents: If bringing your spouse and/or child you must add $6,898 per year of support for a spouse and $3,450 for each child.
Section 1: TO BE COMPLETED BY THE STUDENT:
Please
print
your name clearly as it is listed on your passport.
First name (given name)
Middle name
Last name (family name)
Source of Fun
ds
Amount
Student
US $
Sponsor(s)
US $
Other
US $
Total* US $
I certify that the information I have provided is a correct statement of my financial support. I understand that if these fun
ds are not available,
NOVA is under no obligation to support me and it is likely that I will be unable to continue my education in
the United States. I understand that,
as an F
-1 student, I must enroll in full-time studies, and I am not permitted to work off-
campus without written approval from the Department of
Homeland Security.
Student’s signature Date
Non-Credit IEP with
NOVA's American Culture and Language Institute (ACLI)
Fall/Spring
Summer/Fall/Spring
$10,110
$17,748
$ 1,200
$29,058
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signature
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signature
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5/19
Form 125-067
Page 2 of 2
SPONSOR’S AFFIDAVIT OF SUPPORT
A sponsor may be a parent, family member, or another person who will provide financial support. It is not necessary that a financial sponsor
live in the U.S.
If there is more than one sponsor, please make a copy of this document for each sponsor to complete. One financial sponsor
may provide complete or partial support for the student, but the student’s total financial support must equal or exceed the total estimated
costs (see page 1).
In addition to signing this document, you must provide a bank statement that includes your name, the name of your bank, the statement date,
amount of the available funds and type of currency. The bank statement must be in English, be a certified English translation or clearly show
the information required. The statement must be recent (dated not more than six months before the date classes will begin at NOVA).
This evidence is required to complete an official US government form on which the school official is confirming that financial support is
available. Therefore, Northern Virginia Community College reserves the right to request additional information or clarification.
Section 2: TO BE COMPLETED BY STUDENT’S FINANCIAL SPONSOR
I guarantee that I will be responsible for providing financial support for:
Student’s last name (family name) Student’s first name (given name) Student’s middle name
Amount Promised:
U
S $
Supporting document: In addition to signing this document, you must provide a bank statement that includes your name, the name of your
bank, the statement date, amount of the available funds and type of currency. The bank statement must be in English, be a certified English
translation or clearly show the information required. The statement must be recent (dated not more than six months before the date classes
will begin at NOVA).
Please read carefully and sign below:
I understand that the document I am signing will be used by the student for the purpose of obtaining F-1 status or an F-1 visa from the U.S.
government or for the purpose of updating the student’s SEVIS record. If I am unable to provide the financial support I have promised, I
understand that NOVA is not obligated to support the above named student. I understand that without my financial support, it is likely that the
student will be unable to continue his/her education in the United States.
I understand that F-1 students are not permitted to work off-campus or provide any services in exchange for financial support. I will not
suggest or require this student to provide any services while in the United States.
Sponsor’s Name (please print):
Email address:
Telephone (with country/area code):
Relationship to the student:
Sponsor’s signature: Date:
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Form 125-067B: No I Northern Virginia IA 'WN (Northern Virginia Community College)

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Completed 24 March 2021

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