UNIVERSITY OF MINNESOTA

2010-2011 Financial Certification Statement

Please complete this form and submit it in person to an F-1 adviser at International Student and Scholar Services (ISSS). Please bring your
passport, I-94 card, current I-20, Grad Degree Information form (if applicable), and documented evidence of your funding sources. If you are
living outside of Minnesota, you may submit this form via fax to the number at the bottom of the page.

SECTION I: GENERAL INFORMATION

Student’s Name
Family Name (As it appears in your passport) Given Name Middle

U of M ID# SEVIS ID#

Email Address Phone

Country of Citizenship Country of Birth

Birthdate Passport expiration date Visa expiration date

month/day/year month/day/year month/day/year

First Term/Year Registered at U of MN I-20 expiration date

Foreign Address: U S Address:

Request I-20 Form for following reason(s)—Please check appropriate response.

r Change financial information on I-20
r Program Extension: Academic or Medical Reason (please circle one) (Attach adviser approval letter)
r Change of Degree level/Program/Major: From: To:
r Change of Visa Status: Current status: _________ To: _________ I am ( applying within the US / applying in home country )
r Reinstatement of Student Status (I-20 must be prepared within 30 days of submission to immigration)
r Re-Entry to Regain Legal Status (indicate date of return to US):
r Returning Student (after five or more months absence). Date of return:
month/day/year

r Add F2 dependent(s) rNew to the US and applying within home country.

rCurrently in US and changing status. If changing status within US: ______________
Current status
Dependent information: Print full name as it appears on passport
1)
Name: Family First Middle (please print) UMN ID (if known)

M/F
Birthdate (month/date/year) Country of Birth Country of Citizenship Relationship to F-1 (circle one)

2)
Name: Family First Middle (please print) UMN ID (if known)

M/F
Birthdate (month/date/year) Country of Birth Country of Citizenship Relationship to F-1 (circle one)

3)
Name: Family First Middle (please print) UMN ID (if known)

M/F
Birthdate (month/date/year) Country of Birth Country of Citizenship Relationship to F-1 (circle one)

r End status of F-2 dependent Full name: Family, First, Middle (please print) UMN ID# Reason

r Other:
Ready by: International Student and Scholar Services
190 Hubert H. Humphrey Center, 301 19th Avenue South
Minneapolis, MN 55455
Tel : 612-626-7100 Fax: 612-626-7361
E-mail: isss@umn.edu www.isss.umn.edu
TG 7/10
 Section 2: Estimate of Expenses
A. Educational Expenses - See page 4 for Tuition / Fee 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, calculate your tuition (in box below). If not, move on to line (f).
ASSISTANTSHIP If you have an assistantship, write the
percentage time here. (eg.: 25%) (a) (%)
Multiply by 2. (eg: x 2 = 50%) (b) (%)
Subtract result on line (b) from 100% and write
the remaining percentage here.
(eg: 100%–50% = 50%) (c) (%)

TUITION Write your estimated cost of tuition

from the chart on page 4. (d) $
Multiply (d) by the percentage on
line (c) above.
This is the amount of tuition you pay. (e) $
Enter amount from line (e) on line (f) ?
TUITION Write your estimated cost of tuition for 2 semesters here (f)
(refer to the table on page 4)
INSURANCE Write the cost of student insurance here ($1,860)
(Students with assistantship: $183) (g)

BOOKS, SUPPLIES & FEES Write your estimated cost for the academic year ($2,000-$3,500) (h)

SUMMER TUITION, FEES, If you enroll for summer, write your estimated summer educational cost here: (i)
BOOKS, INSURANCE

TOTAL EDUCATION Add lines (f) through (i) to find your total estimated cost for education

B. Living Expenses These figures are estimates for living expenses for a 12-month period. If you receive free room and board from a spon-
sor, you should indicate here the cost your sponsor incurs on your behalf and list your sponsor as a resource for that
amount in Section 3.

ROOM/BOARD Minimum of $10,101 $

TRANSPORTATION Minimum of $259 $
PERSONAL/MISC. Minimum of $2,667 $

TOTAL LIVING Add all the figures to find your total estimated living expenses: $
$13,030 minimum

C. Dependent’s expenses (if applicable)

•It is your responsibility to provide full health/hospitalization insurance for your dependent(s) immediately upon their arrival in the United States.
•Circle the appropriate number:
1 Dependent $667 per month 4 Dependents $1,376 per month
2 Dependents $938 per month 5 Dependents $1,591 per month
3 Dependents $1,155 per month

TOTAL DEPENDENTS Multiply x _____ months to find your dependent’s living expenses: $

Total Add the figures in the boxes to find your total expenses. $
The figures shown above are an estimate only. The University of Minnesota is not responsible for differences between your actual costs and the figures provided
in this estimate. You should be prepared to find additional funding in the event that there is a sudden change in educational or living expenses.
 Section 3: Sources of Funds
•Please indicate the total resources available to meet your education and living costs during the number of months specified.
•You must show that you have sufficient funds to meet the total expenses shown in Section 2.
Personal funds/savings $

Funds from the U of M (specify type) $

(assistantships, fellowships, etc.)
*You must submit a letter to verify employment and confirm that the next 12 months of expenses will be covered
On-campus employment (if any; specify department) $
(non-assistantship)
Funds from another source (specify source) $

Total Add the figures above to find your total sources of funds. $

Certification by the Student

I certify that the statements given by me in Sections I through III 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 it 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. I also understand
that the cost of my travel outside the United States and any money I might expect to earn during that time will be treated as
income. 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 United States, I may discuss the impact of my financial aid status with a finan-
cial aid adviser at ISSS.
I understand that it is my responsibility to provide health and hospitalization insurance for my dependents who enter the United
States on F-2 visas. I also am aware that dependents in F-2 status are not allowed to earn income in the United States.
By signing below, I verify that I understand the above information. I agree to comply with any decisions—financial or other-
wise—that International Student & Scholar Services makes based upon the information I have given them.

Signature: Date:

Section 4: Passport & Visa Information ISSS staff will complete this section

r Program
r Registration: # of credits
r Holds
r UMN employment verification
r Changes to dependent information
r Give I-20 due date slip to student

Comments:

Received By: Date:

UNIVERSITY of MINNESOTA Professional School Tuition Rates—The following semester rates have been approved
for professional school students and the departmental masters for 2010-11. Some schools
2010-11 Twin Cities Campus Tuition have a 12-19 credit plateau. With this plateau there is no charge (except for course
Tuition rates fees) for the 13th-19th credits. Each credit above 19 is assessed on a per credit basis.
University Fee—The University fee helps cover costs related to instruction, student Departmental masters have a 12-18 credit plateau. Most other schools have term rates for
services, and academic support and is not dedicated to one particular need. This fee is 12 or more credits.
assessed to all students and will be prorated as follows: Carlson School of Management Resident Non-Resident
$65.00 per credit for students taking 1-9 credits; Master of Human Resources & Industrial Relations
$650.00 for students taking 10 credits or more. Full time per credit..............................$761.00....................$1,388.25
Undergraduates (including reciprocity students) who are classified as full time by their 10-15 credits........................................7,610.00..................13,882.50
college are required to pay the full University fee regardless of their credit load. Students Part time per credit..............................781.00......................$1,137.10
must appeal to their college for an exception to full-time classification. Master of Business Administration—entering students (guaranteed two year rates)
Per credit, new students (guaranteed 2-year rate)
Tuition Rates for Undergraduates—The following per-credit semester tuition rates have 1,204.00 ....................1,714.34
been approved for the 2010-11 academic year. Rates do not vary by college of enrollment 12-19 credits..................................... 14,448.00 ................20,572.00
and are the same for all undergraduate students. All degree-seeking undergraduates pay Per credit, continuing students............1,146.00 ....................1,632.66
a flat tuition rate based on a minimum 13-credit load (including audited classes) and 12-14 credits..................................... 13,760.00 ................19,592.00
pay the student services fee, as well as a full technology/collegiate fee. Credits 1-12 are Per credit, evening students.................1,090.00 ....................1,090.00
assessed at the per-credit rate only for those students who have been approved for a 12 or more credits...............................1,090.00 ....................1,579.00
reduced credit load. Non degree-seeking students are charged per credit for credits 1-12 Master of Business Taxation
and a flat tuition rate for 13 or more credits. Per credit (1-11 credits) ......................1,090.00 ..............…..1,090.00
Per credit (12 or more credits) ............1,090.00 ...........….....1,579.00
Undergraduate rates Resident Non-Resident Master of Accounting
Per credit ................................................................$ 376.70 .............$ 824.00 Per credit (1-9).....................................761.00 .......................1,388.25
13-credit band (for 13 or more credits)...................4,897.00 .............10,712.00 10-18 credits .......................................7,610.00 ..................13,882.50
Executive Master of Business Administration
Undergraduate Non-resident admitted fall 2008 or later New students (guaranteed 2-year rate)23,750.00..................23,750.00
Per Credit.... ....................................................................................... $542.08 Continuing students............................23,160.00..................23,160.00
13-credit band.................................................................................... $7,047.00 Colleges of Food, Agricultural, and Natural Resource Sciences (CFANS) & Education
and Human Development (CEHD)
Graduate School Tuition Rates —The following semester rates have been approved Departmental masters Post-baccalaureate certificates
for 20010-11. The plateau for the Graduate School is 6-14 credits. No additional charge Per credit.............................................479.92 ..........................761.92
(except course fees) is made for 7th-14th credits with this plateau. Each credit above 14 12-18 credit plateau.............................5,759.00.....................9,143.00
is assessed on a per-credit basis. School of Dentistry
Semester..............................................13,023.00 .................23,739.00
Part-time rates Resident Non Resident Per Summer Term................................6,964.00...................12,694.00
Per credit .........................................$1,003.67 ....…..$ 1,595.17 Completion per credit..........................521.00...........................950.40
Full-time rates Law School
6-14 credits .....................................6,022.00 ............9,571.00 First Year Students
Each credit over 14 ......................... 1,003.67 ............1,595.17 Per credit ............................................1,201.00 .....................1,555.42
Term (12 or more credits) ...................14,412.00 ........….....18,665.00
Tuition Rates by College & School Second Year Students
College of Continuing Education Per credit ............................................1,134.00 .....................1,555.42
Master of Biological Sciences Term (12 or more credits) ...................13,612.00 ........….....18,665.00
Per credit .........................................1,412.00 ............1,412.00 Third Year Students
Housing Studies Certificate Per credit ............................................1,054.59 ....................1,555.42
Per credit .........................................674.60 ...............674.60 Term (12 or more credits) ...................12,655.00 ........…....18,665.00
College of Design (M.Arch and MLA) LLM per credit.....................................1,605.25.....................1,605.25
Per credit .........................................814.59 ...............814.59 LLM term (12 or more credits)............19,263.00 ................19,263.00
12-17 credits ...................................9,775.00 ............9,775.00 Medical School
Each credit over 17 ..........................814.59 ...............814.59 First year students...............................10,683.00 .................13,773.00
M.S. Design, Housing, and Apparel students: see Graduate School Tuition Rates Second year students ..........................10,176.00 ................12,812.00
College of Liberal Arts Third year students .............................9,691.00 ................. 12,202.00
Master of geographical information system (MGIS) Fourth year students ...........................9,409.00 ................. 11,847.00
Part-time rates, Per credit .................1,049.50 ...........1,668.00 Fifth year students...............................9,135.00 ..................11,502.00
Full-time rates, 6-14 credits..............6,297.00 .......... 10,008.00 Sixth year students...............................8,869.00 ..................11,167.00
Each credit over 14 ..........................1,049.50 .......... 1,668.00 Physical Therapy (DPT)
Humphrey Institute of Public Affairs Per term flat rate................................. 7,104.00 ................. 11,824.00
MDP, MPP, MS-STEP, and MURP Physical Therapy (DPT) Transitional Program
Per credit .........................................1,157.84 ............1,748.00 Part-time, per credit.............................1,003.50 .................. 1,595.00
6-15 credits (*MDP 6-16) ................6,947.00 ...........10,488.00 6-14 credits..........................................6,021.00 ...................9,570.00
Each credit over 15 (*MDP 16)........1,157.84 ............1,748.00 Each credit over 14..............................1,003.50 ....................1,595.00
MPA rates School of Nursing
Per credit (no banding).....................1,003.58............1,595.08 Master of Nursing, per credit................518.73..........................518.73
College of Science and Engineering Doctor of Nursing Practice, per credit..745.56...........................745.56
Master of Management of Technology DNP, 9 credits or more.........................6,710.00 ....................6,710.00
1st year students ..............................15,487.50 ..........15,487.50 College of Pharmacy
2nd year students.............................15,175.00 ..........15,175.00 Per credit .............................................827.00 ..................... 1,301.50
Per credit (special circumstances).....1,675.00 ........... 1,675.00 12 or more credits ...............................9,924.00 ................ 15,618.00
Master of Sciences in Software Engineering School of Public Health
1st year students ..............................7.200.00 ............7,200.00 Master of Public Health (MPH)
2nd year students .............................6,750.00 ............6,750.00 Per credit.............................................665.00 ..........................883.00
Master of Science of Security Technology Per credit summer................................665.00 ..........................665.00
Per credit..........................................1,000.00.............1,000.00 Master of Healthcare Administration
Master of Infrastructure Systems Engineering M.H.A. part time per credit .................1,084.00 ....................1,084.00
First Year...........................................6,700.00.............6700.00 Full time, per credit, & 99 PRD...........665.00 ..........................883.00
Second Year.......................................6,475.00.............6,475.00 Executive Master of Healthcare Administration
Third Year..........................................6,225.00.............6,225.00 Cohort 1 (began 1/2010)......................1,010.00 ...................1,010.50
Per credit (special circumstances)......895.00................895.00 Cohort 2 (began 1/2011)......................1,238.00 .................. 1,238.00
Master of Financial Mathematics Veterinary Medicine, College of
Per credit..........................................750.00.................750.00 Per credit .............................................1,322.67 ...................2,519.67

9 credits or more, flat rate....................11,904.00 ................22,677.00

The University of Minnesota is an equal opportunity educator and employer.