Fillable Instructions Section I. Personal Information ocials may inquire (Florida Polytechnic University)

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Instructions Section I. Personal Information ocials may inquire (Florida Polytechnic University)

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Request for Form I-20 & Certificate of Finances
Instructions
International Students 2020 - 2021
Page 1 | 3
Please review the following instructions before completing the Request for Form I-20.
Section I. Personal Information
What will be your major/program of study? This information is required and will appear on your I-20. 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?
(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. Must be a non-U.S. address to be issued the Form I-20. 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.
Mailing address. Provide 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 International Student Services (ISS)
via e-mail at: ISS@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
USCIS regulations require evidence of financial support to verify 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., to confirm funding sources. 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. Please provide exact amounts for the academic year 2020 – 2021, and for each
subsequent year (2021 – 2022, 2022-2023, and 2023-2024), provide an estimate of the projected funds you plan to
receive.
Florida Polytechnic University Financial Aid. You must provide a copy of your Financial Aid award letter.
Your Personal Funds. Provide a bank statement or certified letter (with an English translation, as applicable) for
any income earned from employment, etc., that will be applied to the costs of your education.
Note: We need to ensure that there is a pattern of assets being set aside for the purpose of funding your education
and understand bank statements may fluctuate. Provide the most accurate information as possible.
Example: If you intend to provide $3,000 and your statement shows a balance of $1,000, that is to be expected. The
amount provided on this form should be the amount you plan to have available at the time you travel to the U.S.
Family/Relative Funds. Provide a bank statement or certified letter indicating the amount of funds your family
members plan to apply towards the costs of your education.
(Please see Note and Example sections above.)
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. List any other funds being provided that do not apply to the previous sections here (stocks, etc.).
Sections IV & V. Verification & Student Signature
Signatures are required from any persons providing funds and the student submitting the I-20 Request.
Request for Form I-20 & Certificate of Finances
International Students 2020 - 2021
Page 2 | 3
AMOUNTS IN USD TUITION &
FEES
ROOM &
BOARD
BOOKS PERSONAL EXPENSE &
TRAVEL
INSURANCE TOTAL ESTIMATED
COA
UNDEGRADUATES
$21,005
$11,800
$4,000
$1,194
$39,199
GRADUATES
$19,998
$11,800
$4,000
$1,194
$38,192
Estimated cost of attendance (COA) includes tuition and fees, room and board, textbooks, personal expenses, travel, and mandatory
insurance, based on undergraduate students enrolled in 30 credit hours over an academic year of 9 months and graduate students
enrolled in 18 credit hours per academic year. Please Note: COA information subject to change without notice.
Section I. Personal Information ___
Please 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 & Country of Birth
Country of Citizenship
County of Permanent Legal Residence
Phone: ___________
Country code City code Number
Email: ______________
What will be your major/program of study? (This will appear on your I-20): ___
*COMPLETED THIS SECTION ONLY IF YOU ARE 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.)? _____________________________
*You must submit photocopies of your current I-20 and I-94 documents with this request form.
Section II. Address Information_________________________________________________________________________________________
You must provide a non-U.S. address to be issued a Certificate of Eligibility (Form I-20. If you want your documents to be
sent via courier/express service (DHL, UPS, FedEx, etc.).
Pl
ease request special handling from International Student Services at: ISS@floridapoly.edu. You will be responsible for paying
any fees associated with this service. *ALL DOCUMENTS WILL BE SENT VIA FIRST CLASS AIR MAIL.*
PERMANENT ADDRESS (Required – this may not be a U.S. address):
House Number & Street (and Apt. # if any)
City
State/Province
Country
Postal Code (if any)
*You may provide a different mailing address if you want your documents to be sent to another location.*
Provide only if you intend to have your I-20 sent to this address!
Mailing Address:
State/Province
Country
Postal Code (if any)
Please complete all sections of this form carefully, include the appropriate information and documentation, and ensure
all applicable sections are signed. Upon receipt of all required documentation the Form I-20 will be mailed within two
weeks. Missing or incomplete information will delay the issuance of your Form I-20
City
Request for Form I-20 & Certificate of Finances
International Students 2020 - 2021
Page 3 | 3
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 USD; if bank statements are not in English, a translation must be provided
• Funds must be liquid assets available for support
• Please indicate any dependents who will accompany you to live in the U.S. during your studies
o Only legal spouse and dependent unmarried children (under age of 21) can be claimed as dependents
o The financial requirement for each dependent is an additional U.S. $3,000
Will dependents accompany you? Yes No (If no, do not complete F-1/J-1 Add/Update Dependent form)
If Yes, please verify how many? (Please ensure to complete the Dependent Form after Section IV)
Source of
Funds
Amount
2020-2021
Projected
Amount
2021-2022
Projected
Amount
2022-2023
Projected
Amount
2023-2024
Documentation
Required
Florida Poly
Financial Aid
$
$
$
$
Copy of Florida Poly Financial Aid letter
Your Personal
Funds
$
$
$
$
Original bank statement
(in English)
Funds from
Family/Relative
(Complete Section
IV)
$
$
$
$
Original bank statement
(in English)
Government or
Sponsoring
Agency
$
$
$
$
Official letter of support from government
of sponsoring agency
Other Source
$
$
$
$
Identify the source of funds and attach
appropriate documentation
TOTAL
$
$
$
$
Amount should be equal to or greater
than the amount that is required to study
for one academic year (or 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 have included bank statements
indicating the availability of these funds.
Sponsor Printed Name
Signature
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 authorize Florida Polytechnic University to access my I-94 arrival and departure date records (accessible
via U.S. Customs and Border Protection website) for immigration and on-campus employment purposes. I understand
that as a non-immigrant student, I am expected to engage in full-time study at Florida Polytechnic University.
Signature Printed Name Date
Return to this form and all required documentation to:
Office of the University Registrar, International Services 4700 Research Way, Lakeland, FL 33805-8531
If you have any questions, please contact your DSO: Phone: 863-874-8723 | Email: ISS@floridapoly.edu
click to sign
signature
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Please use the next page if you are adding more than one dependent.
F-1/J-1 Add/Update Dependent form
Note: This form will update the primary visa holder’s SEVIS record.
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:
Please complete this form only to add, update or delete dependents
Please use duplicate this page if you need list additional dependents.
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:
Please use this form for additional dependents only.
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Instructions Section I. Personal Information ocials may inquire (Florida Polytechnic University)

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Completed 28 January 2021

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