University of Nevada, Las Vegas | School of Dental Medicine... Confidential Financial Certification |

University of Nevada, Las Vegas | School of Dental Medicine F-1 International Student
Confidential Financial Certification |2016-2017 Academic Year
Read These Instructions: Please print clearly or type all required information on this form. Failure to do so will delay or prevent issuance
of your 1-20. A bank letter or statement with an official signature or stamp verifying the availability of the required dollar amount must
accompany this form. A photocopy of a monthly bank statement is NOT sufficient financial verification. The guarantor of funds must sign this
form or it will not be valid.
The confidential financial certification form along with the attached appropriate bank letter MUST be submitted before an I20 will be issued.
DMD: Dr. Christine Ancajas: [email protected]
Orthodontics: Patricia Williams: [email protected] or [email protected]
Pediatrics: Patricia Williams: [email protected]
Student Information
*Please print your name as it appears or will appear on your passport*
Family Name (Surname):
First Name:
E-mail:
Country of Birth:
Middle Name (if applicable):
Date of Birth(month/day/year):
Country of Permanent Residence:
Applying for (Circle One):
Fall 2016
Spring 2017
Have you ever attended a U.S. school with F-1 visa status?
If you are a current F-1 student, are you current on OPT?
If you are currently an F-1 student, Name of the school:
Attended from (month/date/year):
Summer 2017
Yes
Country of Citizenship:
No
Yes
No
to(month/day/year):
Your SEVIS ID # is (It is the number appearing on the right upper corner above the bar code): N
Required Mailing Address for sending the I-20 to you:
Line 1:
Province/State:
City:
Postal Code:
Line 2:
Country:
Required Foreign Address (Home Country Address):
Line 1:
Province:
City:
Postal Code:
Line 2:
Country:
Estimated Expenses
Estimated required expenses of a student for the 2015-2016 academic year include tuition, mandatory student fees, and minimum living
expenses for 12 months. There are additional expenses for dependents in the United States. All fees are subject to change without notice.
DMD
Orthodontics
Pediatrics
General Residency
Tuition & Fees:
$94,368
$85,620
$37,068
N/A
Total required
amount:
$134,715
$153,054
$70,551
N/A
Living expenses:
$40,347
$67,434
Dependent Information for F-2 Visa
$33,483
N/A
Under the U.S. immigration regulations, only legally married spouse and minor unmarried child(ren) under the age of 21 are eligible for F-2 visa and status.
Students should expect additional expenses for each dependent accompanying them to the United States. If your spouse is accompanying you to Las Vegas,
you must show an additional $7,000.00 in available funds. If you have children accompanying you, you must show an additional $3,000.00 for each child.
If your spouse and/or children will come to Las Vegas with you as F-2 visa holders, please provide the following information.
Print or type your dependents' names as they appear on their passports.
Dependent No. 1
Family Name (Surname):
First Name:
Middle Name (if applicable):
Date of Birth (month/day/year):
Country of Permanent Residence:
Relationship to you (check one only):
Dependent No. 2
Family Name (Surname):
Husband
Wife
Son
Country of Citizenship:
Daughter
First Name:
Middle Name (if applicable):
Date of Birth (month/day/year):
Country of Permanent Residence:
Relationship to you (check one only):
Dependent No. 3
Husband
Wife
Son
Country of Citizenship:
Daughter
Family Name (Surname):
First Name:
Country of Permanent Residence:
Country of Citizenship:
Middle Name (if applicable):
Date of Birth (month/day/year):
Relationship to you (check one only):
Husband
Wife
Son
Daughter
Source of Funds
Parents and/or Guarantors (Name and Relationship to You):
Other source of funds (scholarship, government, etc):
Amount of Funds: $
Amount of Funds: $
*Please note that all international students on an F or J Visa, who receive a scholarship, fellowship, and/or stipend payment from UNL V will be taxed 14% on
room and board expenses, living allowances or athletic/fellowship stipends.
Other Financial Sources (Please specify):
Amount of Funds: $
Total Assured Support Amount in U.S. Dollars Only:
$
Certification of Sources of Funds
This is to certify that I have read the information furnished by the applicant on this form, that it is a true and accurate statement, and that the funds listed
above are available. A signed letter must be attached from the bank official stating the amounts listed above.
Guarantor of Account Holder Must Sign Below or This Form Is Not Valid
This is to certify that I, the parent and/or guarantor will provide the following support to the applicant. (For example: tuition, fees, housing, etc.). To
substantiate your financial guarantee, you as sponsor, are asked to attach a letter from an officer of your bank or other similar proof of available finances for
this student's education.
Guarantor's Signature:
I certify that the information provided above is correct and complete.
Student's Signature:
Relationship to Applicant:
Date(month/date/year):