Financial Certification Statement

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1 Financial Certification Statement Please complete and submit this form in person to an F-1 adviser at International Student & Scholar Services (ISSS). Bring your passport, current I-20, and documentary evidence of your University of Minnesota funding sources (if applicable). Section 1: General Information Please note: Your name on this application must match your name as it appears on your passport. 1. Student s Name 2. U of M ID# 3. SEVIS ID # Phone I-20 expiration date (if applicable) 8. Passport expiration date 9. Visa expiration date First Term/Year Registered at U of M 13. US Address 14. Check appropriate reason for requesting a new I-20 (Reason continues on Page 2) Update I-20 expenses and/or funding Program Extension Academic Reason (attach adviser letter) Medical Reason (attach doctor letter and adviser letter stating expected date of completion) New end date: Change of: Degree level / Major (circle one) From: To: If you are currently on OPT, what is your requested OPT end date? Change of Visa Status: Semester you would like to begin in F1 status: Current status: Home country address: Street Name & Number Apartment/Room Number I am applying within the US applying in home country City Province Country Zip/Postal Code I am currently enrolled in an academic program at the U of M starting a new academic program at the U of M Please Turn Over. Reason continues on the next page.>>>>>>>>>> 1 International Student & Scholar Services 190 Humphrey, th Avenue S Minneapolis, MN U.S.A. (612) Fax (612) Ready by:

2 Regain Legal Status: Reinstatement by applying within the U.S. (I-20 must be prepared within 30 days of submission to USCIS) Re-entry (indicate date of return to the US): Add F2 dependent(s) New to the US and applying within home country. Currently in the US and changing status. If changing status within the US Current status Dependent information: Print full name as it appears on passport Dependent 1: Dependent 2: Dependent 3: End status of F-2 dependent U of M ID # Reason (required) Other: 2

3 Section 2: Estimate of Expenses A. Educational Expenses (See page 5 for tuition rates) Number of months covered by Financial Certification: (Minimum: 1 month) You must show funding for 12 months unless your I-20 expires in less than 1 year. If you have an assistantship, write the percentage time (e.g. 25%) TUITION Estimated cost of tuition for 2 semesters INSURANCE Cost of student insurance ($2,254) (Students with 50% assistantship: $219) BOOKS, SUPPLIES & FEES Estimated cost for the academic year ($2,000-3,500) SUMMER TUITION, FEES, BOOKS, AND INSURANCE TOTAL EDUCATION Summer educational cost (if applicable) Add items (a) through (d) for total estimated educational expenses (a) (b) (c) (d) (e) B. Living Expenses The figures below are estimates for a 12-month period. If receiving free room and board from a sponsor, indicate here the cost the sponsor incurs and list the sponsor under funds from another source in Section 3. ROOM/BOARD Minimum of $11,461 TRANSPORTATION Minimum of $300 PERSONAL/MISC. Minimum of $3,000 TOTAL LIVING C. Dependent Expenses (if applicable) Add items (f) through (h) for total estimated living expenses Minimum of $14,761 (f) (g) (h) (i) NOTE: It is the student s responsibility to provide health insurance for dependent(s) immediately upon their arrival in the US Check the appropriate box below: 1 Dependent $691 per month 4 Dependents $1,425 per month 2 Dependents $971 per month 5 Dependents $1,647 per month 3 Dependents $1,196 per month TOTAL DEPENDENTS Multiply X months for total estimated dependent expenses (j) TOTAL EXPENSES Add the amounts in (e), (i), and (j) for total expenses $ *The figures shown above are an estimate only. The University of Minnesota is not responsible for differences between actual costs and the figures provided in this estimate. The student should be prepared to find additional funding in the event that there is a sudden change in educational or living expenses. 3

4 Section 3: Sources of Fundsof Funds Indicate financial resources available to meet educational and living expenses during the number of months specified in Section 2. Students must be able to show sufficient funds to meet the total expenses shown in Section 2. Personal funds/savings Funds from the U of M (*Bring documentary funding evidence for the number of months specified in Section 2) On-campus employment (non-assistantship) Funds from another source [specify type (e.g. assistantships, fellowships, etc)] [specify department] [specify source (e.g. family)] (k) (l) (m) (n) TOTAL FUNDING Add the amounts in (k), (l), (m), and (n) for total funding $ Section 4: Certification by the Student STATEMENT: I certify that the statements given by me in Sections 1 through 3 of this form are complete and accurate for the next 12 months. I understand that this information will be used in generating an I-20, and that is illegal to provide false information on that document. I take financial responsibility for all my educational and personal expenses should my source of funding specified above be interrupted or stopped; the University of Minnesota accepts no responsibility for my financial needs. If I am applying for ISSS/University financial aid, I know that it is possible to lose funding if the information I have provided on this document is not consistent with the information on my financial aid application. I understand that, before making a decision about temporarily leaving the US, I may discuss the impact of my financial aid status with a financial aid adviser at ISSS. I understand that it is my responsibility to provide health and hospitalization insurance for my dependents who enter the US on F-2 visas. I also am aware that dependents in F-2 status are not allowed to earn income in the US. By signing below, I verify that I understand the above information. I agree to comply with any decisions - financial or otherwise - that International Student & Scholar Services makes based upon the information I have given them. Student s Signature ISSS will complete this section: Enrollment: (# of credits) Program Plan Holds U of M employment verification Changes to dependent information COS: Requested begin date/semester on I-20: Give I-20 due date slip to student Date submitted to ISSS International student adviser initials Adviser Comments 4 07/2015

5 UNIVERSITY of MINNESOTA Twin Cities Campus Tuition Tuition Rates for Undergraduates As a degree-seeking undergraduate student, you must pay a flat tuition rate based on 13 credits, no matter what your credit load. This means that any credits beyond 13 are available at no additional charge. Even when you take 12 ore fewer credits, you must pay the 13-credit flat tuition rate. You will be charged per credit for credits 1-12 only if you are pre-approved to register for less than 13 credits. Undergraduate rates (Per semester) Resident Non-Resident Per credit...$ $ credit band (for 13 or more credits)...6, , Graduate School Tuition Rates The following semester rates have been approved for The general graduate tuition rate includes 6-14 credit band for full-time registration. Each credit above or below the plateau is assessed on a per-credit basis. Part-time rates Resident Non Resident Per credit...$1, $2, Full-time rates 6-14 credits...7, , Each credit over , , Tuition Rates by College & School College of Design (M.Arch and MLA) Per credit...1, , credits...12, , Each credit over , , Humphrey School of Public Affairs MDP, MPP, MS-STEP, and MURP Per credit...1, , credits (*MDP 6-16)...9, , Each credit over 15 (*MDP 16)...1, , MPA rates Per credit (no banding)...1, , College of Liberal Arts Master of Geographic Information System (MGIS) Per credit...1, , Full-time, 6-14 credits...8, , Each credit over , , College of Science and Engineering Master of Management of Technology (MSMOT) Entered Fall , , Entered Fall 14, or later...1, , Master of Sciences in Software Engineering (MSSE) 1st year students...8, , Master of Science of Security Technology (MSST) Per credit...1, , Master of Financial Mathematics (MFM) Per credit Per credit (entered Fall 12 or later) , Professional School Tuition Rates The following semester rates have been approved for professional school students and the departmental masters for Some programs have a credit plateau for which no charge (except course fees) is made for credits. Each credit above 19 is assessed on a per-credit basis. Departmental masters have a credit plateau. Most other programs have semester rates for 12 or more credits. Carlson School of Management Resident Non-Resident Master of Accountancy Per credit (1-9)...$ $1, credits...9, , Each credit over , Master of Business Administration (MBA) Per credit, new students (guaranteed 2-year rate) 1, , credits...18, , Per credit, continuing students...1, , credits...17, , Per credit, evening students...1, , Eac credit over , , Executive Master of Business Administration Entering Students, guaranteed 2-year rates 27, , Master of Business Taxation (MBT) Per credit (1-11 credits)... 1, , Per credit (12 or more credits)... 1, , Master of Arts in Human Resources & Industrial Relations (MA-HRIR) Full time per credit , credits...9, , Each credit over , Master of Science in Business Analytics Per credit , credits or more... 13, , Center for Allied Health Programs Master of Occupational Therapy Per semester...11, , Per credit , School of Dentistry 1st & 2nd year students Semester...$16, $30, Summer Term... 9, , Completion per credit , Master of Dental Therapy Students admitted before Fall 13 Semester...7, , Students admitted Fall 13 or later Per semester...7, , Completion per credit College of Education and Human Development (CEHD) Departmental masters Post-baccalaureate certificates Per credit , credits...7, , Humphrey School of Public Affairs Master of Public Affairs Leadership Master of Policy Issues on Work and Pay Per credit...1, , Master of Nonprofit Management Per credit...1, , credits...10, , Law School Year 1 (entering Fall 15) Per credit...1, , Term (12 or more credits)...20, , Year 2 Per credit...1, , Term (12 or more credits)...20, , Third Year Student Per credit...1, , Term (12 or more credits)... 20, , LLM Term...24, Medical School (Flat rate per term) First year students...12, , Second year students...12, , Third year students...12, , Fourth year students...12, , Fifth year students...11, , Sixth year students...11, , Physical Therapy (DPT) Per term flat rate... 8, , School of Nursing Master of Nursing (MN) Per credit DNP Per credit credits or more...8, , DNP, post-master of Nursing Per credit College of Pharmacy Years 1-3, Per credit... 1, , Term...12, , School of Public Health Master of Public Health (MPH) Per credit , Per credit summer Master of Healthcare Administration Evening, per credit...1, , Others, per credit , Executive Master of Healthcare Administration Cohort 3 (begins 1/2012)...1, , Cohort 4 (begins 1/2013)...1, , Cohort 5 (begins 1/2014)...1, , Cohort 6 (begins 1/2015)...1, , Cohort 7 (begins 1/2016)...1, , Saudi Arabia...1, College of Veterinary Medicine Per credit...1, , credits or more, flat rate... 14, , The University of Minnesota is an equal opportunity educator and employer.

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