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Graduate Supplemental Form 2151

The document is an international student supplemental form from the University of Pittsburgh's Office of International Services. It contains instructions for completing biographical information and certifying financial resources. There are two parts to the form: Part I requests biographical data and immigration information, while Part II requires certification of sufficient financial support to cover estimated costs of attendance, supported by bank statements or other documentation. Students must complete both parts and submit all requested materials for the university to issue student visa documents.

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57 views4 pages

Graduate Supplemental Form 2151

The document is an international student supplemental form from the University of Pittsburgh's Office of International Services. It contains instructions for completing biographical information and certifying financial resources. There are two parts to the form: Part I requests biographical data and immigration information, while Part II requires certification of sufficient financial support to cover estimated costs of attendance, supported by bank statements or other documentation. Students must complete both parts and submit all requested materials for the university to issue student visa documents.

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Mind Props
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© © All Rights Reserved
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The University of Pittsburgh

Office of International Services

International Graduate Student Supplemental Form 2014-2015


The Office of International Services (OIS) has prepared this form to facilitate the issuance of student visa documents (Form I-20 or
DS-2019) to international graduate students. There are two parts to the form.
PART I:

PART II:

The first part is biographical information that is required of all students classified as international (non-immigrant)
students. The information in Part I of the form is required to be submitted with your acceptance of the offer of
admission.
The second part of the form is the Certification of Financial Resources. This part of the form must be completed
and submitted together with original financial documents, such as a bank statement, before your file can be
processed for a student visa document.

To ensure the process goes smoothly and is completed in a timely manner, it is important that you read and follow the instructions on
this form carefully and provide all requested information. This will avoid delays in the processing of your file and the issuance of visa
documents once your file is submitted to OIS. For additional information, please visit www.ois.pitt.edu or email oisnew@pitt.edu.

Part I: Biographical Information


Biographical Information
Name: (Print your name EXACTLY as it appears in your passport and provide a copy of your passport identification page.)

Family Name
Gender: Male

Female

Given Name
Marital Status: Married

Single

Middle Name
Date of Birth (mm/dd/yyyy)

Academic program to which you have been admitted:


City of Birth:

Country of Birth:

Country of Citizenship:

Country of Legal Permanent Residence:

Position/Occupation in Home Country:


(e.g., student, professor, etc.)
Address in Home Country (must be an address outside the United States):
Street Address
City, State/Province
Country and Postal Code
Telephone___________________________Fax______________________________E-Mail______

____________________

Address to Which Visa Documents Should Be Sent (if different from home country address):
Street Address
City, State/Province
Country and Postal Code
Telephone___________________________Fax_____________________________ E-Mail
If the above is a temporary address, indicate the last date you can receive mail at this address: (mm/dd/yyyy)

Immigration Information
If you are currently INSIDE the United States, please complete and submit the following:
1. Current Visa Status:

Current Sponsor/School:

2. Date Current Visa Status Expires: (mm/dd/yyyy)

3. Please attach supporting documentation verifying current visa classification (e.g., Form I-20, Form DS-2019, etc.).
If you are currently OUTSIDE the United States, please complete the following:
1. Have you previously been inside the United States in F1 status? Yes

No

2. If yes, provide the dates of your program (including any post-completion optional practical training authorization) and attach a copy of
your most recently issued Form I-20. From: (mm/dd/yyyy):

to (mm/dd/yyyy):

Dependent Information
For each dependent who will accompany you to the U.S., please provide the following information. Use additional sheet if necessary.
Please note that a dependent is defined as your spouse and/or any unmarried children under 21 years of age.
1. Gender:

Male

Female

Relationship:

Name: (Print the name EXACTLY as it appears in the passport.)


Family Name

Given Name

Middle Name

Date of Birth (mm/dd/yyyy)_____ / _____ / _____ City & Country of Birth:


Country of Citizenship:
2. Gender:

Male

Country of Residence:
Female

Relationship:

Name: (Print the name EXACTLY as it appears in the passport.)


Family Name

Given Name

Middle Name

Date of Birth (mm/dd/yyyy)_____ / _____ / _____ City & Country of Birth:


Country of Citizenship:
3. Gender:

Male

Country of Residence:
Female

Relationship:

Name: (Print the name EXACTLY as it appears in the passport.)


Family Name

Given Name

Middle Name

Date of Birth (mm/dd/yyyy)_____ / _____ / _____ City & Country of Birth:


Country of Citizenship:

Country of Residence:

The statements and information provided on this application are true and accurate to the best of my knowledge.

Student Signature

Date

Part II: Certification of Financial Resources


You must review the following instructions before completing and signing this form. Failure to properly complete the form and provide acceptable
proof of financial support will result in delays in the processing of your visa document.

1.
2.

3.

4.
5.

6.

Review the cost estimates (below) and the estimated length of the degree program to which you are applying. Be sure to include
additional costs for any dependents who will accompany you to the U.S.
Students who have been awarded full financial support from the University of Pittsburgh covering all estimated tuition/fees,
health insurance, and living expenses (Teaching Assistantship, Graduate Student Researcher, etc.) do not need to complete and
submit Part II except to cover additional dependent expenses, if applicable.
Complete the certification indicating the amount of support that will be provided for each year of the program. In addition, you
must attach proof, such as a bank statement or letter, of immediately available liquid assets for the first 12 months of study. Real
estate or other non-liquid assets such as automobiles, jewelry, or other personal property cannot be used to demonstrate financial
support for the first 12 months but may be provided as evidence of support for subsequent years of study.
All proof of financial support must be original documents in English. Documentation must be issued within the last six months,
and the date the document was issued must be clearly indicated.
Evidence of financial support must also be shown to the U.S. Consulate when applying for a visa. Therefore, you will need to
have two sets of financial support documentsone to submit to the University of Pittsburgh and one for the U.S. Embassy or
Consulate.
Students may provide proof of financial support from more than one sponsor. The attached form may be copied and provided to
any additional sponsors.

Graduate Cost of Attendance Figures for 2014-2015


The estimates below are based on actual costs for Academic Year 2013-14. For immigration purposes, providing evidence of
financial support to meet the costs outlined below is sufficient; however, please note that actual costs will likely increase for the
2014-2015 academic year. Students should add $4,020 per year for each dependent family member (spouse and/or unmarried
children under the age of 21) who will accompany them to the U.S. The dependent estimate does not include health insurance.
School
Tuition & Fees*
12 Mo. Living Insurance** Total/Year
School of Arts & Sciences, School of Education, and Graduate
$33,426
$15,580
$2,148
$51,154
School of Public & International Affairs
$27,736
$15,580
$2,148
$45,464
School of Social Work
$38,268
$15,580
$2,148
$55,996
Swanson School of Engineering
$37,604
$15,580
$2,148
$55,332
School of Law (MSL & JD)
$35,420
$15,580
$2,148
$53,148
School of Law (LLM)
$35,110
$15,580
$2,148
$52,838
School of Information Sciences
$53,572
$15,580
$2,148
$71,300
School of Dental Medicine (except as below)
$27,737
$15,580
$2,148
$45,465
School of Dental Medicine (MS, PhD in Oral Biology)
$48,818
$15,580
$2,148
$66,546
School of Dental Medicine (First Professional)
$27,736
$15,580
$2,148
$45,464
School of Nursing
$24,850
$15,580
$2,148
$42,578
School of Pharmacy (Graduate)
$31,610
$15,580
$2,148
$49,338
School of Pharmacy (First Professional)
$39,096
$15,580
$2,148
$56,824
Graduate School of Public Health
$36,406
$15,580
$2,148
$54,134
School of Medicine (Graduate)
$39,096
$15,580
$2,148
$56,824
School of Health and Rehabilitation Sciences (except as below)
School of Health & Rehabilitation Sciences (MOT, CSD
$27,736
$15,580
$2,148
MA/MS, AuD, Rehabilitation Counseling MS, Prosthetics
$45,464
and Orthotics MS, and CMD MS)
School of Health & Rehabilitation Sciences (MS PT)
$ 53,650 (3 semesters)
$15,580
$2,148
$71,378
School of Health & Rehabilitation Sciences (DPT)
$41,409 (3 semesters)
$15,580
$2,148
$59,137
Katz Business School Doctoral Program
$36,694
$15,580
$2,148
$54,422
Katz Business School MS Accounting
$34,914
$15,580
$2,148
$52,642
*From http://www.ir.pitt.edu/tuition/index.html. Except as noted, figures above include tuition and mandatory fees for two semesters.
**Health insurance is required for all full-time international students at the University of Pittsburgh.

The University of Pittsburgh


Office of International Services

Certification of Financial Resources


Note: This form may be copied if more than one individual will be contributing to your financial support.

Students Name
Family Name

Given Name

Middle Name

Given Name

Middle Name

University of Pittsburgh Academic Program

Sponsors Name
Family Name
Sponsors Address (Number and Street):

City:

State/Province:

Country:

Postal Code:

Phone:

E-Mail:

Relationship of Sponsor to Student:

Certification of Financial Responsibility


Please complete the chart below for each year that you intend to provide financial support for this student. Funding for the first year
must be in immediately available liquid assets. Funding for subsequent years can be documented through long-term investments or
assets.
I certify that I will provide the following support for the student listed above to study at the University of Pittsburgh.
Year One

Year Two

Year Three

Year Four

Year Five

1. Amount provided each year from annual salary/income.


You MUST attach documentation of salary/income.

_________

_________

_________

_________

________

_________

_________

_________

_________

________

_________

_________

_________

_________

________

_________

_________

_________

_________

________

2. Amount provided from bank account(s),


You MUST attach an official bank statement.
3. Amount provided from other sources.
You MUST identify source(s) and attach documentation.

4. Total Available from All Sources:

Signature of Sponsor

Date Signed

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