Fill - Free fillable Michigan F-1 student severe economic hardship request form PDF form

F-1 Student Severe Economic Hardship

Request Form

Page 1 of 1 Rev 5/07 DP

08/18

1500 Student Activities Building  515 E. Jefferson Street  Ann Arbor MI  48109-1316

TEL: 734.764.9310  FAX: 734.647.2181  EMAIL: icenter@umich.edu  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

applicable.

LAST NAME FIRST NAME MIDDLE NAME

UNIQNAME

UMID #

DATE OF BIRTH (mm-dd-yyyy)

GENDER

 FEMALE  MALE

NUMBER of F-2 DEPENDENTS

TELEPHONE

SEVIS ID #

DELIVERY METHOD

 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

status.

 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 ______________________________

Fill Online, Printable, Fillable, Blank Michigan F-1 student severe economic hardship request form Form