F-1 Student Severe Economic Hardship
1500 Student Activities Building 515 E. Jefferson Street Ann Arbor MI 48109-1316
TEL: 734.764.9310 FAX: 734.647.2181 EMAIL: firstname.lastname@example.org WEB: internationalcenter.umich.edu
Please read “F-1 Employment Based on Severe Economic Hardship” before completing the request
form. You must set up an appointment with an International Student & Scholar Advisor (ISSA) at the
International Center (IC) to review and submit your application.
Attach a copy of personal statement and any supporting documentation.
Attach copies of your current and previous I-20s.
Attach a copy of paper or print-out of electronic Form I-94.
Attach a copy of your F-1 visa page (except Canadians) OR approval of change of status to F-1 (I-797) if
LAST NAME FIRST NAME MIDDLE NAME
DATE OF BIRTH (mm-dd-yyyy)
PICK-UP (If someone else will pick up for you, his/her name is: )
SHIP (See “SHIPPING OPTIONS”) : eShip Global U.S. Mail
Employment Dates (1 year maximum): begin (mm/dd/yyyy) ___________; end (mm/dd/yyyy) __________
I have been in F-1 status for at least one academic year: Yes No
I certify I have read the request form instructions and information in full.
I certify the information I have provided is, to the best of my knowledge, accurate.
I understand I (and any F-2 dependents) must have U-M approved health insurance for the duration of my F-1
I understand I must report any address changes, current (U.S.) or permanent (out of U.S.), through Wolverine
Access within 10 days of the change.
Signature ______________________________________________________ Date ______________________________