Virginia Tech
Financial Certification Form for 
Undergraduate International Students
 
Name: ___________________________________________________________________________________________________________
Last (Family Name) First Middle

Mailing Address (I-20AB or DS2019 will be sent to this address. Please be neat.):

(1st line) _________________________________________________________________________________________________________
(2nd line if necessary) ________________________________________________________________________________________________
City _______________________________________________ State/Country __________________________________________________
Country of Birth: _________________________________________________ Date of Birth ______/______ /___________________________
Country of Citizenship: ____________________________________________ Requested Major: ___________________________________
Seeking Admission for term:     ___ Fall     ___ Summer and Fall           Year _________
Marital Status:     ___ Single     ___ Married                  Gender:     ___ Male     ___ Female
The following dependents will accompany me: (Please give name, gender, place and date of birth of each dependent.)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________

_____________________________________  _____________________________________
Signature Date

SOURCE AND AMOUNT OF SUPPORT
Fill in amounts in US dollars in the appropriate category or categories.
1st year
2nd year
3rd year
4th year
5th year
Personal          
Parents          
Government Agency:
(name) _________________
_______________________		          
Other: (specify)
_______________________
_______________________		          
 
OFFICIAL CERTIFICATION OF FUNDS
Please attach a bank statement or an official letter of award as appropriate.