Request for Form I-20 & Certificate of Finances
Instructions
International Students 2020 - 2021
Section I. Personal Information
(Student must complete all sections, unless exempted from specific items listed below.)
In what subject area do you plan to study/major? This information is required and will appear on your I-20. In addition, consular
officials may inquire about your course of study, so be sure that it accurately reflects your academic interests (i.e., Computer Science,
Business Analytics, Mechanical Engineering, etc.).
If you are currently in the U.S., what is your visa status? Please indicate whether it is an F1, H4, R2 or any other type of non-
immigrant visa.
*Students studying in the U.S. must submit photocopies of current I-20 and I-94 documents with their application form.
Section II. Address Information
Permanent Address. Your permanent address must be a non-U.S. address in order for an I-20 to be issued to you. If you are currently
living in the U.S., you must provide the address of a relative or friend abroad who will be able to retrieve your documents if necessary.
Mailing address. Only complete this if you want your documents to be sent to an address other than your permanent address.
Issuance of documents. Form I-20 will be mailed first-class, air mail. If you prefer to have documents mailed via courier service (DHL,
UPS, FedEx, etc.), you must request special handling from the Admissions Office via e-mail at: admissions@floridapoly.edu
You must also
provide billing information as you are solely responsible for all fees associated with this service.
Section III. Source and Amount of Funding
According to USCIS regulations, the international student advisor is required to receive and evaluate evidence of financial support to verify
that students will be able to sufficiently cover the costs of their education. Original documents or certified copies/letters must be provided by
banks, sponsoring agencies, etc., as necessary, to confirm funding sources. The amounts provided must be equal to or greater than the
estimated total cost of attendance for 2018-2019 ($39,199 for undergraduates and $38,192 for graduates).
Source of Funds for 2020 - 2024. You must provide exact amounts for the academic year 2020 - 2021. For each subsequent year
(2021 – 2022, 2022-2023, and 2023-2024), provide an estimate of the projected funds you plan to receive. Therefore, if you anticipate
the amount of financial aid, family income, etc., to remain relatively the same, you may duplicate those amounts in the appropriate
columns.
Florida Polytechnic University Financial Aid. You must provide a copy of your Financial Aid award letter.
Your Personal Funds. You must provide a bank statement or certified letter (with an English translation, as necessary) for any income
earned from employment, etc., that will be applied to the costs of your education. While it is likely that the bank statement will fluctuate,
please provide as accurate information as possible. For example, if you intend to provide $3,000 and your bank statement indicates a balance
of $1,000, that is to be expected. We need to ensure that there is a pattern of assets being set aside for the purpose of funding your education.
The amount that you provide on this form should be the amount you plan to have available at the time you travel to the U.S. to pursue your
studies. You will have the opportunity to declare any dependents that will accompany you.
Family/Relative Funds. You must provide a bank statement or certified letter indicating the amount of funds that your family members
plan to apply to the costs of your education. While it is likely that the bank statement will fluctuate, please provide as accurate information as
possible. For example, if you intend to provide $3,000 and your bank statement indicates a balance of $1,000, that is to be expected. We need
to ensure that there is a pattern of assets being set aside for the purpose of funding your education. The amount that you provide on this form
should be the amount you plan to have available at the time you travel to the U.S. to pursue your studies.
Government or Sponsoring Agency. If you will receive any money (scholarships, grants) in addition to, or in place of, the funding
sources listed above, you must provide the official letter(s) of support/award, along with the amount.
Other. Any other funds being provided that do not apply to any of the previous sections should be listed here (stocks, etc.).
Sections IV & V. Verification & Student Signature
Signatures are required for any person(s) providing funds, as well as for the student submitting the application.
Request for Form I-20 & Certificate of Finances
Instructions
International Students 2020 - 2021
Return this form
(along with the necessary documentation) to:
Office of Admissions Florida Polytechnic University
4700 Research Way
Lakeland, FL 33805-8531
Or Email to: admissions@floridapoly.edu
The total estimated undergraduate cost of attendance of
$39,199 is based on an undergraduate student enrolled
in 30 credit
hours over an academic year of nine months, including
Per academic year
Tuition and Fees
Undergraduate
$21,005
Graduate
$19,998
tuition and fees, room and board, textbooks, personal
Room and Board
$11,800
$11,800
expenses and travel, mandatory insurance.
Books (estimated) $ 1,200
$ 1,200
Estimated graduate total cost of attendance is $38,192
Personal Expenses & Travel
$ 4,000
$ 4,000
for a student enrolled in 18 credit hours per academic
year. Please note that the cost of attendance information
Insurance(estimated)
$ 1,194
$ 1,194
is subject to change without notice.
TOTAL ESTIMATED COST OF ATTENDANCE
$39,199
$38,192
Section I. Personal Information
Please complete the sections below. Type or print clearly. Your name must be consistent with all of your immigration documents.
Check one: Male Female
Name (as on passport):
(Family / Last Name) (Given / First Name) (Middle)
Date of Birth
Day / Month / Year
City and Country of Birth Country of citizenship
Country of
Permanent Legal Residence
Phone:
Country code City code Number
Email:
In what subject area do you plan to study/major? (This information will appear on your I-20):
For students currently studying at another U.S. institution*:
If you are currently in the U.S., what is your visa status (i.e., F1, H4, etc.)?
*Students already studying in the U.S. must also submit photocopies of their current I-20 and I-94 documents with this form.
Section II. Address Information
In order to be issued a Certificate of Eligibility (Form I-20), you must provide a non-U.S. address. However, you may provide a
different mailing address if you want your documents to be sent to another location. ALL DOCUMENTS WILL BE SENT VIA
FIRST CLASS AIR MAIL.**
PERMANENT ADDRESS
(Required – this may not be a U.S. address):
House Number and Street
Apt. # (if any)
State/Province
Country
MAILING ADDRESS
(complete this only if you intend to have your I-20 sent to this address):
House Number and Street
Apt. # (if any)
State/Province
Country
**If you want your documents to be sent via courier/express service (DHL, UPS, FedEx, etc.), please request special handling from the Office of
Admissions via: admissions@floridapoly.edu
You will be responsible for paying any fees associated with this service.
Please complete this form carefully. In order to receive a Certificate of Eligibility (Form I-
20), which is required for you to apply for an F1 student visa stamp at a U.S. Embassy or
Consulate, you must complete all sections of this form and provide the appropriate
documentation to verify that you are able to cover the minimum expenses required for study
at Florida Poly (see chart below). Florida Poly must confirm that sufficient funds will be
available to you throughout your course of study. Any lack of documentation or incomplete
information will delay the issuance of your Certificate of Eligibility. All information will be
kept confidential in accordance with federal law. Therefore, please complete and return this
form at your earliest convenience.
Section III. Source & Amount of Funding
Please complete all of the sections below and attach the required documentation. All financial documents must be originals; photocopies and faxes are
not sufficient. All amounts must be quoted in U.S. dollars. If bank statements are not in English, a translation must be provided. Funds must be liquid
assets available for support. Please also indicate any dependents who will accompany you to live in the U.S. during your studies. Only your legal
spouse and dependent unmarried children under the age of 21 can be claimed as dependents. The financial requirement for each dependent is an
additional U.S. $3,000.
Will dependents accompany you? Yes No If yes, How many? Also complete the Dependent Information Form
Source of Funds Amount
2020-2021
Amount
2021-2022
(projected)
Amount
2022-2023
(projected)
Amount
2023-2024
(projected)
Documentation Needed
Florida Polytechnic University
Financial Aid
$ $ $ $
Required: Copy of your Florida Poly
Financial Aid Award letter.
Your Personal Funds
Name of Bank:
$ $ $ $
Original bank statement. Provide an
English translation, as necessary.
Family/Relative Funds
Name:
Relationship to you:
Occupation:
Employer:
Education:
$ $ $ $
Original bank statement and signature
(see Section IV, below). Provide an
English translation, as necessary.
Name:
Relationship to you:
Occupation:
Employer:
Education:
Government or Sponsoring
Agency
Source:
$ $ $ $
Official letter of support from the
government or sponsoring agency.
Other
Source:
$ $ $ $
Describe the source of funds and attach
the appropriate documentation.
TOTAL $ $ $ $
This amount should be equal to or
greater than the amount that is required
to study for one academic year or nine
(9) months.
Section IV. Verification
Sponsor's statement:
This is to certify that I / we the undersigned have agreed to provide the funds indicated above to the applicant for the purpose of full- time
study at Florida Polytechnic University, and that I am / we are submitting bank statements indicating the availability of these funds.
Sponsor's Signature
Printed Name
Date
Relationship to Applicant
Sponsor's Signature
Printed Name
Date
Relationship to Applicant
Section IV. Student Signature
Student's statement: This is to certify that the information given on this form is complete and accurate to the best of my knowledge. I also authorize Florida Polytechnic University
to access my I-94 arrival and departure date records (accessible through U.S. Customs and Border Protection website) for immigration and on-campus employment purposes. I
under
stand that as a non-immigrant student, I am expected to engage in full-time study at Florida Polytechnic University.
Signature Printed Name Date
Immigration documents will be mailed within two weeks following the receipt of this form, provided that you have completed and
returned the appropriate paperwork. Should you have any questions, please contact:
Office of Admissions
Phone: 863-874-4774 Email: admissions@floridapoly.edu
Please use this page if you are adding more than one dependent.
Advisor initials:
F-1/J-1 Add/Update Dependent form
This form must be completed to add, update or delete a dependent from the primary visa holder's SEVIS record. Please review our website
for more instructions.
Student Information:
First Name: Last Name:
Student ID: SEVIS ID:
First Semester at Florida Poly:
Action requested:
Add dependent to: I-20 DS-2019
* F-1 or J-1 must provide proof of: (1) Financial documentation; A copy of your proof of funding, such as a recent official bank statement;
a letter (on bank letterhead with the bank officer’s signature, seal or stamp) confirming your funds; or a Florida Polytechnic University letter
of funding. Multiple funding sources are permitted. (2) A copy of the dependent’s passport.
Delete dependent’s: I-20 DS-2019
Change an existing dependent’s I-20 DS-2019
Change an existing dependent’s information
Legal name change (must provide copy of passport)
Other:
Dependent information:
Family Name: First Name:
City of Birth: Date of Birth:
Country of Birth: Gender: Male Female
Country of Citizenship: Dependent Relationship: Spouse Child
Country of Permanent Legal Residence:
4700 Research Way. Lakeland, FL 33805-8531 Date received:
(863)-874-4774
www.floridapoly.edu - admissions
@floridapoly.edu Pick-up on:
Purpose:
Please use this page if you are adding more than one dependent.
Advisor initials:
Additional Dependents:
Family Name: First Name:
City of Birth: Date of Birth:
Country of Birth: Gender: Male Female
Country of Citizenship: Dependent Relationship: Spouse Child
Country of Permanent Legal Residence:
Family Name: First Name:
City of Birth: Date of Birth:
Country of Birth: Gender: Male Female
Country of Citizenship: Dependent Relationship: Spouse Child
Country of Permanent Legal Residence:
Family Name: First Name:
City of Birth: Date of Birth:
Country of Birth: Gender: Male Female
Country of Citizenship: Dependent Relationship: Spouse Child
Country of Permanent Legal Residence:
Family Name: First Name:
City of Birth: Date of Birth:
Country of Birth: Gender: Male Female
Country of Citizenship: Dependent Relationship: Spouse Child
Country of Permanent Legal Residence:
4700 Research Way. Lakeland, FL 33805-8531 Date received:
(863)-874-8774
www.floridapoly.edu - admissions@floridapoly.edu Pick-up on:
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