CERTIFICATION OF SOURCES OF FUNDS
AND AMOUNTS AY 2015-2016
Deadline for the Spring 2016 Semester Enrollment: Friday, December 4, 2015
(U.S. Eastern Standard Time)
Personal Information
[1] Name (Please write in the same English spelling as your passport, in CAPITAL LETTER)
Last
First
[2] □ Female
□ Male
Middle (if applicable)
□ Prefer Not to Identify
[4] Date of Birth:
[3] Marital Status □ Single □ Married □ Other
[5] Country of Birth:
[6] Country of Citizenship:
[8] Your passport is issued by
(City)
[7] Country of Permanent Residency (if any)
Expiration Date:
(Name of Country)
*If you have more than one citizenships, please enter name of country that you will be claiming for the US visa application.
[9] Address in Home Country:
(City/Town/Village)
(State/Province/Prefecture)
[10] Phone Number :
(Postal Code)
(Country)
[11] Email :
(Country Code)
Admitted Program Information
[12] Program:
□ MALD
□ MIB
□ MA
□ LLM
□ PhD
□ Exchange Program
[13] Are you Dual-Degree student from the following school?: □ CEIBS □ DA □ HEC
□ St. Gallen □ Other:
□ IE
□ ISB
[14] Are you expected to complete Summer ESL (English as Second Language) program in order to be fully matriculated into
the Fletcher School program in Fall?:
□ Yes □ No – please go to question [15]
[14-A] If “Yes,” are you enrolling to Tufts Summer English Language program? □ Yes □ No –
Name of English School
IMPORTANT – If you are enrolling to a “non-Tufts” English program in Summer, you need to obtain an I-20 from the English school first and request I-20 transfer to the Fletcher
School before coming to our program in Fall.
U.S. Visa Information
[15] Type of visa the student applies
please
check
Visa
Description of Funds
F-1 Visa
If funds are based on or combination of: Student’s own
funds, family (parents, siblings), relatives, Fletcher /
Bosworth scholarship, current employer (include government
offices), educational loan, non-governmental scholarship,
personal/individual friends
If more than 50% of total estimated expenses (per year)
are covered by one of the Fletcher School scholarship
awards;
or
If funds are based on student’s home country
government scholarship or funds by an organization that
is not a designated organization by the U.S. Department
of States to issue DS-2019s.
J-1 visa
Who Issue Certificate of Eligibility?
I-20 will be issued by the Fletcher
School
DS-2019 will be issued by the
Fletcher School
*Not applicable for Semester-Based
Exchange Student.
ATTENTION J-1 student and his/her dependent (J-2 visa holder, spouse/child of J-1) MUST meet the J visa health insurance guideline that the U.S.
Department of States mandates for its J visa applicants and bears in order to enable themselves to apply for the visa. Please read and sign Page 5 of
this form.
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CERTIFICATION OF SOURCES OF FUNDS
AND AMOUNTS AY 2015-2016
[16] Are you currently in the U.S. under a non-immigrant visa status as of today?
□ Yes
visa, valid until: (Date)
*Put “D/S” if you are F or J visa status holder
□ No – please directly go to question [19]
[17] If you are currently in the U.S., do you need to apply for a different visa than the current visa in order to enroll to
the Fletcher School?
□ Yes – Filing a change of status in the U.S. □ Yes – Return to home country and apply at U.S. Embassy
□ No*
*If No, are you an international student (F-1 or J-1) of a different institution than the Fletcher School?
□ Yes – N
SEVIS ID no. (I-20 or DS-2019)
Name of Institution
Date of I-20 or DS-2019 End Date
□ No – I am not an international student. I have a visa status that allows me to pursue full time study in the U.S.
*If you have an U.S. visa status that permits you to study in full-time bases, please directly go to page 3 and sign. Once signed,
please submit this form along with a copy of your passport and visa stamp via email to: Reiko Morris, International
Student Advisor and Assistant Registrar, the Fletcher School at Tufts University: [email protected]
[18] Do you need to obtain a new Certificate of Eligibility (with new SEVIS ID number) from Fletcher?
□ Yes – required to pay a SEVIS Fee (I-901 Fee, $200) online and may need to apply for a new visa
□ No, I will request my current institution to transfer my SEVIS record to Fletcher – Transfer Form submission required
[19] Do you need to request a Certificate of Eligibility (I-20 or DS-2019) for your dependant(s)?
□ Yes – please fill out the Dependant section and attach a copy of your dependant(s)’ passport
□ No – please go to question [20]
(Dependent: 1) □ Spouse (□ Male / □ Female)
Last
City of Birth
First
Country of Birth
(Dependent: 2) □ Spouse (□ Male / □ Female)
Last
City of Birth
□ Child* (□ Male / □ Female)*must be younger than 21 years old
Middle
Country of Citizenship
Country of Permanent Residency (if any)
□ Child* (□ Male / □ Female)*must be younger than 21 years old
First
Country of Birth
Date of Birth (MM/DD/YYYY)
Middle
Date of Birth (MM/DD/YYYY)
Country of Citizenship
Country of Permanent Residency (if any)
*If you have more than one dependent to accompany, please make a copy of this page and attach it to rest of your form.
Shipping Preference for Receiving Certificate of Eligibility (I-20 / DS-2019)
[20] Do you wish us to send your Certificate of Eligibility (I-20 or DS-2019) by Fed-Ex?
□ Yes - we will charge the cost to your Tufts University billing account
□
No - we will send by the United States Postal Service (regular air-mail or domestic mail service)
[20-A] Do you wish to receive your Certificate of Eligibility (I-20 or DS-2019) at your home country address (as you listed
on page 1)?
□ Yes
□ No, please send to the following address:
(Street/Road)
Phone :
(Town/City)
(Province/State/Prefecture)
Certification of Sources of Funds and Amounts_AY2015-2016-Januarian_16
(Postal Code)
Page 2
(Country)
(Country Code)
The Fletcher School_10212015_RM
CERTIFICATION OF SOURCES OF FUNDS
AND AMOUNTS AY 2015-2016
How to Submit Form
1. Scan the completed form along with all applicable documents and send them via email to Reiko Morris:
[email protected]
Deadline – Friday, December 4, 2015 in the U.S. Eastern Standard Time
Document Submission Check List
Please check box of documentation that you need to submit. Your Certificate of Eligibility (I-20 or DS-2019) will be issued once
all the required documents are submitted to the Fletcher School:
Required for ALL Student
□ Official Certification of Sources of Funds and Amount Form – completed, signed and certified by all necessary
parties
□ Copy of a valid passport (with minimum 6 months of validity )
□ Separate Funding proof; (such as personal bank statement, scholarship award letter, government financial assistant
statement, private educational loan statement/guaranteed letter)
Required for ONLY Fletcher School Sponsored J-1 Visa Applicant
□ J Visa Health Insurance Requirements Information and Certification Form (Page 5 of this form) – it is mandated
for all J visa applicants to understand and comply the U.S. Department of State’s health insurance guideline in order
to apply and maintain the visa status. Please read, sign and submit this page with rest of your documents.
Required for Student who Transfers from Another U.S. Institution (including Tufts Language Institute)
Addition to the above-mentioned documentations;
□ Fletcher School International Student Transfer Form – request it to the Fletcher School Registrar’s Office
□ Copy of all previous I-20s or DS-2019s from current US Institution
□ Copy of visa stamp
□ Most recent I-94 (Arrival/Departure) record print-out *Download from CBP web site (www.CBP.gov/I94)
□ Copy of EAD Card for OPT employment – if applicable
□ Copy of your dependant(s)’ previous I-20 or DS-2019 from current US Institution – If applicable
□ Copy of your dependant(s)’ visa stamp – if applicable
Required for Student who Accompanies Dependent(s)
Addition to the above-mentioned documentations;
□ Copy of a valid passport (with minimum 6 months of validity ) of all dependent(s)
Required for Student who Accompanies Same-Sex Spouse
□ Copy of marriage certificate – must be written in English or with a notarized English translation
(NOTE FOR SAME-SEX MARRIED COUPLE)
On June 26, 2013, the United States Supreme Court ruled that Section 3 of the Defense of Marriage Act (DOMA) is unconstitutional. The Department of
State, Bureau of Consular Affairs has advised consulates (the US Embassy or Consulate) that their officials may issue derivative visas based on same-sex
marriage if the marriage is “recognized in the place of celebration.” That is, if the country where the couple married recognizes same-sex marriage as
legal, then the U.S. government will recognize the union as legal for visa issuance, irrespective of where the couple plans to reside.
The Fletcher School may issue a Certificate of Eligibility (I-20 or DS-2019) to your same-sex spouse of for his/her F-2 or J-2 dependent visa application,
once the marriage is verified.
2. Send original of your form and all necessary documents via regular airmail to the following office address:
Reiko Morris, International Student Advisor
The Fletcher School
Tufts University
160 Packard Avenue
Medford, MA 02155 U.S.A.
Ph: +1-617-627-3055
STUDENT CERTIFICATION
I hereby certify that information I provided here on this form as well as the attached funding sponsor
information are true and accurate.
Student’s Name (Print)
Certification of Sources of Funds and Amounts_AY2015-2016-Januarian_16
Student’s Signature
Page 3
Date
The Fletcher School_10212015_RM
CERTIFICATION OF SOURCES OF FUNDS AND AMOUNTS
AY 2015 - 2016
Funding Sponsor Information Page
The Fletcher School Law and Diplomacy Academic Programs and Costs
The 2015-2016 Academic Year (September 2015 – May 2016 / 9 months)
Tuition
MALD/MA/LLM/PhD
$42,234.00†
$49,434.00†
MIB
Exchange Program (One semester only)
No cost
Room & Board
MALD/MA/MIB/LLM/PhD
$14,500.00 (Single student, 10 months / Off-Campus)
Exchange Program
Funding / Financial Sponsor Information
*Separate funding document(s) required. Attach it/them to this form.
Funding Source and Amount
Please list all applicable funding information in below. Certified funds are expected to
be available, in full, upon your arrival at The Fletcher School.
$7,200.00 (Single student, 4 months / Off-Campus)
University Health Insurance Fee *Mandated for all F-1 and J-1 students to enroll
MALD/MA/MIB/LLM/PhD
$2,451.00† (Single student unless waived in advance)
□ Personal / Self Funds
$_______________________
□ Family Funds
$_______________________
[Name: ___________________________________
Relationship to Student: _____________________________]
[Name: ___________________________________
Relationship to Student: _____________________________]
Certification by Personal/Family Funds Sponsor
Exchange Program
$927.00† (One semester / 4 mouths)
Student Health Services Fee (Mandated for all students)
MALD/MA/MIB/LLM/PhD
$761.00†
Exchange Program
$379.00†
I hereby confirm that I provide total of US$____________________ as I indicated
in the above section, for (Name of Student)
, who
will be a student at the Fletcher School during the 2015-2016 academic year.
Name of Sponsor: ______________________________________________________
Books, Supplies & Personal Expenses
MALD/MA/MIB/LLM/PhD
$3,250.00 (Estimate)
Signature of Sponsor: ____________________________ Date: _________________
Exchange Program
$1,625.00 (Estimate)
*If you have your own/personal funds, please write your name under “Name of Sponsor” section and
sign. If your attached funding document carries all information above, you may opt this section.
TOTAL (Estimated)
MALD/MA/LLM/PhD
$63,196.00†
□ Scholarship from Fletcher School
MIB
EXCHANGE PROGRAM
$70,396.00 †
$10,131.00 †
□ Other Scholarship [Name
] $_______________________
□ Employer [Name
] $_______________________
† Subject to approval by Trustees of Tufts College.
Expenses for Dependent (per 10 months)
Spouse
Child (Must be younger than 21 years old)
$4,000.00
$3,000.00
□ Educational Loan
$________________________
□ Home Government Scholarship/ Stipend
$________________________
(If applicable)
*In addition, extra costs for dependent’s health insurance fee need to be estimated.
□ Additional Funds [Name
IMPORTANT All fund(s) you list on this form MUST BE fully granted /
confirmed and available on the date you submit it to the Fletcher School.
Please do NOT include any “pending status” funds (i.e. scholarship, loan)
information.
Total Amount of Funds
Certification of Sources of Funds and Amounts_AY2015-2016-Januarian_16
$_______________________
] $_______________________
US$__________________________
*In order to comply with the U.S. immigration regulation, total amount of your enrolling
program MUST BE certified and confirmed in order to issue Form I-20 or DS-2019.
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CERTIFICATION OF SOURCES OF FUNDS
AND AMOUNTS AY 2015-2016
Funding Documents Information Page
Funding Source and Amount
Please list all applicable funding information. Funds and financial sponsorship information that you list on this form will be reported to
the U.S. Department of Homeland Security, and must be available, in full, upon your arrival at The Fletcher School.
(IMPORTANT)
1. Please attach separate document(s), such as bank statement and scholarship letter, of all of your funding sources to this form. If
you are granted scholarship, please attach a copy of your scholarship information/document (for Fletcher Scholarship, a copy
of admission letter) or email printouts.
2. If you will are using an educational loan as a part of your funding, you may submit application confirmation/statement. However,
your I-20 cannot be issued until your loan approval statement/confirmation is submitted to the Fletcher School.
3. We do NOT accept the following document for I-20 issuances:
•
investment portfolios;
•
retirement plans;
•
available lines of credit (including credit card) ;
•
deed to real state;
•
leases with rental income;
•
salary agreements or paystubs;
•
income tax forms;
•
public provident funds.
4. Funding document(s) must be issued within 6 months from the date you fill out this form.
5. Amount of funds can be in a foreign currency. But it must be stated in numeric figures (e.g.: ¥1,800,000, € 65,000)
6. If your funding information is only in a foreign currency, please attach foreign currency exchange printouts from an internet
currency exchange site (e.g.: XE.com.) Otherwise, we will obtain currency exchange rate information of the date when your I-20 is
issued.
7. We do NOT accept funding document that is written only in non-English language. If needed, please attach an English translation
of the document.
The Fletcher School – Degree Program and Costs
Tuition
MALD/MA/LLM/PhD
MIB
Exchange Program )
(One semester only)
Room & Board
MALD/MA/MIB/LLM/PhD
$42,234.00†
$49,434.00†
No cost
(Single student, 10 months / Off-Campus)
Exchange Program
(Single student, 4 months / Off-Campus)
University Health Insurance Fee
*Mandated for all F-1 and J-1 students to enroll
MALD/MA/MIB/LLM/PhD
Exchange Program
†
(Single student unless waived in advance)
Exchange Program
$927.00†
$7,200.00
Student Health Services Fee
*Mandated for all F-1 and J-1 students to enroll
MALD/MA/MIB/LLM/PhD $2,451.00
$14,500.00
$761.00†
$379.00†
(One semester / 4 mouths)
Books, Supplies & Personal Expenses
MALD/MA/MIB/LLM/PhD
$3,250.00 (Estimate)
Exchange Program
$1,625.00 (Estimate)
Expenses for Dependent (per 10 months)
Spouse
$4,000.00
Child (Must be younger than 21 years old)
$3,000.00
*In addition, extra costs for dependent’s health insurance fee need
to be estimated.
TOTAL (Estimated)
MALD/MA/LLM/PhD
MIB
EXCHANGE PROGRAM
$63,196.00†
$70,396.00 †
$10,131.00 †
† Subject to approval by Trustees of Tufts College.
Certification of Sources of Funds and Amounts-Funding Documents Information Page
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CERTIFICATION OF SOURCES OF FUNDS
AND AMOUNTS AY 2015-2016
J-1 Exchange Visitor Program: Fletcher School Sponsored Students
J Visa Health Insurance Requirement Information and Certification Form
Please fill out and submit this form ONLY IF you are applying for J-1 visa
THE EXCHANGE VISITOR PROGRAM (from the U.S. Department of State Welcome Statement)
THE U.S. DEPARMENT OF STATE administers the Exchange Visitor Program under the provisions
of the Mutual Educational and Cultural Exchange Act of 1961, as amended. The Act promotes
mutual understanding between the people of the United States and other countries by means of
educational and cultural exchange. The Exchange Visitor Program provides foreign nationals
opportunities to participate in exchange programs in the United States with the expectation that on
completion of their exchange program, they will return home to share their experiences.
INSURANCE RULES
You are required to have medical insurance in effect for yourself (J-1) and any dependents (J-2) for
the duration of your program. Some sponsors provide the required insurance for their participants.
Other sponsors may allow you to make your own arrangements or may help to identify insurance
carriers. Consult with your responsible officer before the start of your program.
A. Minimum Insurance Coverage (new rule, effective on May 15, 2015) – Insurance shall cover:
(1) Medical benefits of at least $100,000 per person per accident or illness;
(2) In the case of death, repatriation of remains in the amount of $25,000; and
(3) Expenses associated with medical evaluation in the amount of $50,000 of the J-1 and J2 visa status holder to his/her home country
B. Additional Terms – A policy secured to fulfill the insurance requirements shall not have a
deductible that exceeds $500 per accident or illness, and must meet other standards
specified in the regulations.
C. Maintenance of Insurance – Willful failure on your part to maintain the required insurance
throughout your stay in the United States will result in the termination of your exchange
program.
IMPORTANT TO KNOW: Tufts University Health Insurance Purchase
It is mandated for primary visa holder of J visa (J-1 student) to purchase the University
insurance plan when he/she starts academic program here at the Fletcher School (Tufts
University.) However, if his/her dependent (spouse or child) would prefer to purchase an U.S.
insurance (non-Tufts University) policy that meets ALL of the above-mentioned insurance
requirements, the J-2 dependent may do so and submit “University Health Insurance Policy
Waiver Form” to the University Health and Counseling Office (120 Professors Raw).
Please be mindful that there is a deadline to submit the University Insurance Waiver Form AND
the document needs to be submitted DIRECTLY to Tufts University Health Services office
(http://ase.tufts.edu/healthservice/business.htm) at 120 Professors Row at Tufts Medford campus.
Please go to the above-mentioned web page to get more detail information.
STUDENT CERTIFICATION
I hereby certify that I read all the content of this form, and will comply the U.S. Department of State’s J visa health insurance requirements in order to maintain my J visa
status.
Student’s Name (Print)
Certification of Sources of Funds and Amounts_AY2015-2016-FL15_J Visa Insurance Form
Student’s Signature
Page 6
Date
The Fletcher School_10212015_RM