U of M ID# if known

Twin Cities

Financial Certification Statement

for 2009-2010 international students

U.S. Department of Homeland Security regulations require that the University maintain records showing that you have met its
financial requirements (as well as its academic and language proficiency requirements). You are responsible for demonstrating that
you have sufficient funds to meet all educational and personal expenses for the duration of your F-1 status at the University.
You must fill out all the information on this form before the University of Minnesota will issue you an I-20. If you are a resident of
Manitoba, Canada, please request the financial certification statement for Manitoba residents from the Office of Admissions or download
it at http://admissions.tc.umn.edu/PDFs.
You must certify that you have at least the amount necessary to cover your tuition, fees, and living expenses for your first academic year
(12 months). If you attend summer session and/or bring your spouse or other dependents with you to the United States, you must certify
that you have the additional amount necessary to cover those costs.
Complete this form carefully to avoid lengthy delays that may affect your academic plans. We will return forms that are
incomplete or that do not show adequate financial resources. Do not send bank statements.

Name and permanent address

Name

(PLEASE PRINT) first middle last or family name former date of birth (month, day, year)

Permanent address Please provide your permanent address in your home country.

Expenses (estimated) Resources

List the amount in U.S. dollars that is available
to you from each of your financial resources.

1. Undergraduate tuition, fees, 7. Personal funds $

and mandatory health insurance $ 17,322
for 2009-2010 academic year 8. Family funds from abroad
$
List name and relationship to you:

2. Living expenses, including

$ 14,800
book expenses, for 12 months

3. Subtotal $ 32,122 9. Scholarship, grant or loan

$
List name and address of source:

4. Summer school tuition, fees,

and health insurance: $
$8,661 (if needed)
10. Funds from another source
$
Specify type, source and address:
5. Living expenses for spouse/
children (See back of this form for figures $
and requested dependent information.)

6. Total (Add lines 3 through 5) $ 11. Total (Add lines 7 through 10)
$
This amount should equal or exceed the total from line 6.

Form continues on back side ➥

 Dependent information
Complete the following information for each dependent of the F-1 student who is seeking entry/re-entry to the U.S.
family name first name date of birth (month, day, yr) country of birth relationship to F-1 student

Living expenses of dependents

(for 12 months)

One dependent $ 7,704

Two dependents $ 10,824

Three dependents $ 13,320

Four dependents $ 15,876

Five dependents $ 18,892

Applicant’s signature
I certify that the above information is complete, accurate, and true. I take full financial responsibility for all of my educational and personal expenses.
I understand that the University of Minnesota accepts no responsibility for my financial needs.

signature date (month, day, year)

Return this form to:

*005026*
Office of Admissions, University of Minnesota–Twin Cities
240 Williamson Hall, 231 Pillsbury Drive S.E., Minneapolis, MN 55455-0213 or fax to: 612-626-1693