TO: Prospective Student

FROM: International Student Office

RE: Application Packet for Admission

Thank you for your interest in Guilford Technical Community College

(GTCC)! We look forward to receiving your application for admissions.

To become a student with F-1 Visa Status, you will need to submit a

completed application packet to our International Student Office.

Enclosed you will find the college guidelines and admissions

requirements. Please read them carefully and fill out the forms completely.

Your accuracy in providing us with all the necessary information will save

time in reviewing and processing your application. A completed

application packet will also provide us the information needed to prepare

your student 1-20 form. Do not mail it to us before you are able to

complete and enclose all the items listed on the Student Admission Check

List sheet.

Should you need any additional information, please visit the following

link for International Students:

http://supportservices.gtcc.edu/international-student/ .

We are available to help you with any academic questions and concerns

regarding your admissions, so please feel free to email us @

internationalstudents@gtcc.edu or call us directly at 336-334-4822 ext.

50076.

**Notice as of March 1** All students applying to the college must

submit an RCN number on their application (question number 17). Please

visit the following site to obtain your RCN number:

www.ncresidency.org. Failure to submit your RCN number on your

application will result in your application being denied.

Thank you in advance,

Student Success Center

Guilford Technical Community College

Jamestown Campus, Medlin Building, Room 202C

601 E. Main Street, Jamestown, NC 27282

E-mail: internationalstudents@gtcc.edu

Direct: 336-334-4822 ext. 50076

GTCC INTERNATIONAL STUDENT ADMISSIONS APPLICATION PROCESS

1. APPLICATION FOR ADMISSION (Do not complete the online application. If you have, please let us know. Otherwise, complete the paper application in this packet.) &

NON-REFUNDABLE APPLICATION FEE: $40.00

2. RDS WEBSITE: Please go to the link www.ncresidency.org

3. ACADEMIC RECORDS:

a. A High School Diploma is required, no exceptions.

b. A certified copy of the original educational record/transcripts, to include all previous academic experiences is required. If the original copy of this record

is written in a language other than English, then a certified copy of an English translation is required.

c. Transfer Credit: Transfer credit for international transcripts can be granted once their international transcripts have been verified by a recognized

translation entity such as World Education Services (WES). If you have US college credit we will need those transcripts as well.

4. ENGLISH PROFICIENCY: One of the following requirements are acceptable.

a. Your country of citizenship is a English speaking country. Verified by PDSO.

b. TOEFL: The Test Of English as a Foreign Language is required of all applicants, except those from countries where English is the only official language,

or the applicant is a transfer student from an accredited U.S. college or institution with English transfer credit. The minimum acceptable TOEFL score

of score of 65+. School Code: 5275—We must receive official copies of the scores.

c. Academic International English Language Testing System (Academic IELTS) - Before entering a full-time academic (college) program, a student is

required to have a minimum Academic IELTS score of 6.5 overall band score.

d. Completion of a Language School— You must complete all levels of the language school-no exceptions.

5. AFFIDAVIT OF SUPPORT:

a. A completed Form I-134 and/or GTCC Financial Certificate, signed and notarized signature on financial resource statement is required of all applicants.

b. The supporter must provide an official letter from his/her banking institution giving information on the types of account (s), balance (s) and length of time

he/she has been banking with the institution.

c. A bank statement dated within the last 90 days.

d. A minimum of $15,000.00 in supporter’s bank account annually.

e. A minimum of $4,000 deposit upon admission to the college.

6. REPORT OF MEDICAL HISTORY:

a. A completed statement of medical history signed by a practicing

physician is necessary. Use provided medical form.

b. A record of updated immunization history is also needed. If you have not had all required immunizations, you will be required to have them prior to

acceptance.

7. TRANSFER CLEARANCE:

a. A Transfer Clearance Form must be completed by all students who are currently residing in the United States for the purpose of attending school. The last

authorized institution attended must complete this form. A copy of your I-20 is also required.

8. PASSPORTS/VISAS/I-94: We must have copies of your passport, visa, and I-94.

*Upon receipt of all items listed above, an admission decision will be made and the applicant will be notified as soon as

possible. If the decision is a positive one, then a U.S. Department of Justice Form I-20 A-B Certification of Eligibility will be

prepared and forwarded with a formal acceptance letter.

CONTACT US:

General Questions: internationalstudents@gtcc.edu

Office Phone: 336-334-4822 or 336-454-1126 ext. 50076

Fax Number: 336-819-2045

Important Notes

* All items requested must be official. For Change of Status, you would have to complete the I-539 form in addition to

including these items and other required items.

* GTCC does not issue an I-20 (Student Visa) for students attending ESL/ESOL classes only. ESL classes are available

through the Continuing Education Program. ESOL classes are free of charge.

APPLICATION FOR ADMISSION Guilford Technical Community College P.O. Box 309 ♦ Jamestown, NC 27282 If you have questions about this application, call 336-334-4822/336-454-1126

Please read before completing application

• To be admitted to a curriculum, you must be a high school graduate or have a high school equivalency (GED) certificate. If you do not want to work toward a degree, diploma or certificate, you can enroll as a special credit student.

• You must have official transcripts from your high school or GED and each post-secondary institution mailed directly to the Admissions Office.

All students, including special credit/non-degree seeking students MUST provide evidence of having met all course prerequisites before being allowed to register for classes.

• Students should complete their admissions file prior to enrollment. Failure to do so may impact registration.

Instructions: Please type or print in ink. Please write legibly. Respond to all questions completely, use your legal name and return the application

to the Admissions Office at the address shown above. Incomplete applications will be returned.

Have you previously applied to GTCC? Yes

Currently enrolled, applying to a limited enrollment program? Yes

* This information is required if you intend to file for Financial Aid and to provide verification of the 1. / / Hope tax credit.

*Social Security Number

2. Last Name First Middle Former

3.

Address City State Zip

4. County of legal residence State of legal residence Country of legal residence

5. ( ) ( )

area code Cell phone area code Home phone

6. Date of birth: / / (mmddyy) 7. * Ethnicity: Hispanic or Latino Yes No

8. * Race: Choose one or more: White Black or African American Native Hawaiian or Other Pacific Islander

Asian American Indian or Alaskan Native

9. * Gender: F M 10. E-Mail Address:

11. Year/Term entering 20 Fall Spring Summer

12. Curriculum for which you are applying or Program of interest: (Please indicate one program only)

13. Nursing Applicants check one option only: RN Program (Fall start) RN Program (Spring start) PN (Fall start) If you are currently an PN are you interested in: Bridging (Summer start)

14. Enrolling as a: Freshman (No previous college course work) Transfer (Any previous college course work) Returning GTCC student

15. Long term goal at GTCC (check one only): GR To obtain an Associate Degree Diploma or Certificate

TR To take courses to transfer to another college without earning a degree at GTCC

EP To enhance job skills in present field of work

EN To enhance employment skill for a new field of work

PE To take courses for personal enrichment or interest

GU Undecided

Federal regulations require that institutions provide consumer information about the school. (Over)

The Consumer Disclosure is located at: http://www.gtcc.edu/departments/financialAid/generalInfo/consumerInfo.html

16. I am currently: GTCC Employee Military/ Military Dependent Consortium

If you are a veteran, please check one of the three following categories: Special Disabled Veteran Vietnam Era Veteran Other Eligible Veteran

17. What is your RCN Number? _______________ www.ncresidency.org

Y (If no, proof of residency status must accompany application.)

If no, status: Resident Alien Refugee Visa Visa type

Country of Origin

19. * Employment Status:

E1 1-10 hrs./week E2 11-20 hrs./week E3 21-39 hrs./week E4 40+ hrs./week R Retired UN Unemployed- not seeking employment US Unemployed-seeking employment

21. High School Status: Currently enrolled in high school

High school graduate

Certificate of completion

GED graduate

Adult high school graduate

(through a community college)

Did not graduate

23. Highest grade father completed (check one):

Less Than 10th 13 -- Adult HS (through a community college)

10th 14 -- College Vocational Diploma

11th 15 -- Associates

12th 16 -- Bachelors

GED 17 -- Masters or higher

20. Highest grade student completed (check one):

Less Than 10th 13 - Adult HS (through a community college) 10th 14 - College Vocational Diploma

11th 15 - Associates

12th 16 - Bachelors

GED 17 - Masters or higher

22. High School Track(s): - College Tech Prep/Tech Prep

- General Prep

OT - Other Track

- Unknown Track

- College Prep

- Vocational Prep

24. Highest grade mother completed (check one):

Less Than 10th 13 - Adult HS (through a community college)

10th 14 - College Vocational Diploma

11th 15 - Associates

12th 16 - Bachelors

GED 17 - Masters or higher

25. High school attended: City County State __

26. High school graduation: What year did you graduate? ; or What year will you graduate? 27. Is/was your high school: public, private, homeschool or correspondence school?

28. If GED/AHS graduate where it was earned? Month and Year Earned: /

(state)

29. If GED/AHS graduate, last school attended prior to earning GED/AHS: Last Year Attended: (state)

30. List all colleges attended: (Please list full college name) From (Yr.) / To (Yr.)

College City/State Dates /

College City/State Dates /

College City/State Dates /

I certify that the information on this application is correct and complete. I understand that providing false or incomplete answers may disqualify me from admission and enrollment at Guilford Technical Community College.

I agree to abide by the rules and regulations of the college when I am admitted as a student.

/ /

Signature Date

* This is voluntary information used for Federal reporting and has no bearing on admission to the college.

GTCC is an Affirmative Action/Equal Opportunity College. 01/17

* This is voluntary information used for Federal reporting and has no bearing on admission to the college.

GTCC is an Affirmative Action/Equal Opportunity College.

Rev. 3/17

Yes NO Relationship

Tuberculosis Diabetes Heart Disease Kidney Disease Arthritis Stomach Disease Asthma or Hay Fever Epilepsy, Convulsions

Yes No

A. Do you have any disease, or is any drug or other treatment being followed which should be continued or periodically evaluated? (Give details)

B. Have you any drug allergy or other known sensitivity or intolerance? (Give details)

C. Have you had any illness, injury, or operation, or been hospitalized other than as already noted? (Give details)

D. Has your physical activity been restricted during the past five years? (Give reasons and duration)

E. Have you ever been hospitalized for mental or emotional illness? (Give name(s) and address(es) of doctor(s) and hospital(s))

F. Have you ever interrupted school or work either because of mental or emotional illness or alter psychiatric consultation? (Give details and

doctor(s) name(s) and address(es))

G. Have you been tested for the HIV/AIDS virus?

REPORT OF MEDICAL HISTORY

PLEASE COMPLETE THIS SIDE BEFORE GOING TO YOUR PHYSICIAN FOR EXAMINATION

LAST NAME (Print) FIRST NAME MIDDLE . TELEPHONE NUMBER

HOME ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE COUNTRY

M F SINGLE MARRIED OTHER

DATE OF BIRTH SEX MARITAL STATUS

YES □_ NO □ FALL □ SPRING □ SUMMER _□ PREVIOUSLY ENROLLED HERE? PROPOSED DATE OF REGISTRATION YEAR

NAME OF HEALTH INSURANCE COMPANY COMPANY ADDRESS & PHONE NUMBER POLICY NUMBER

NAME & RELATIONSHIP OF NEXT OF KIN Have any of your relatives had any of the following?

ADDRESS OF NEXT OF KIN PHONE NUMBER

PARENTS OF STUDENTS UNDER 18: I hereby authorize any medical Treatment for my son/daughter which may be advised or recommended.

SIGNATURE OF PARENT OR GUARDIAN DATE

PERSONAL HISTORY: PLEASE ANSWER ALL QUESTIONS Comment on all positive answers in space below or on additional sheet.

HAVE YOU HAD YES NO YES NO YES NO YES NO

Eye Trouble Frequent or Severe Respiratory infections

Kidney or Bladder Disease Diabetes Ear, Nose, Throat Trouble Infectious Mononucleosis

Frequent or Severe Headaches Rheumatic Fever or

Heart Murmur Disease or Injury of Bones or Joints FEMALES ONLY Epilepsy Stomach or Intestinal

Trouble “Trick” Knee, Shoulder, etc. Irregular Periods Asthma, Hay Fever, Hives Severe Cramps Tuberculosis Hepatitis or Jaundice Anemia Excessive Flow

REMARKS OR ADDITIONAL INFORMATION

(Use additional sheet if necessary)

STATEMENT BY STUDENT: I have personally supplied the above information and attest

that it is true and complete to the best of my knowledge.

A photocopy of this permission is to be considered as valid as original.

Signature of Student Date Physician’s Signature (Acknowledging Review) Date

VACCINE DATE DATE DATE DATE DATE

DPT *Td or Tetanus Booster Polio, oral **Rubeola (measles) Mumps Rubella (German Measles)

Yes No

1. Head, ears, nose or throat 2. Eyes 3. Respiratory 4. Cardiovascular 5. Gastrointestinal 6. Hernia 7. Genitourinary 8. Musculoskeletal 9. Metabolic/Endocrine 10. Neuropsychiatric 11. Skin

MEDICAL EXAMINATION

TO THE EXAMINING PHYSICIAN: This form MUST be completed in its ENTIRETY. Please review and sign the student’s history on the front before completing the physical examination. Please comment on all positive answers. The information supplied will be used as a background for providing health care. This information is strictly for use of Guilford Technical Community College to provide necessary services, and will not be released without the student’s consent.

LAST NAME FIRST NAME MIDDLE DATE OF BIRTH

Height Inches Weight Pounds Blood Pressure / Pulse /min.

VISION: Corrected Right 20/

Left 20/

Hearing (gross):

Uncorrected Right 20/

Left 20/

Right

Left

URINALYSIS HEMATOCRIT

Sugar %

Albumin

Micro

Tuberculin Skin Test (Required Yearly)

Date Positive/Negative (circle)

Chest X-Ray/Date Report

Are there abnormalities of the following systems?

Immunizations Required for Admission to College

North Carolina state law requires that all new undergraduate and graduate students entering college must have certain required immunizations. Immunization records must be kept on file at the college. Students taking both day and night classes are required to present proof of immunization. Students enrolled in four semester hours or less and residing off campus are exempt from this law. Students attending night classes, weekend classes or off-campus courses only are also exempt.

HISTORY OF IMMUNIZATIONS

NOTE: *Measles after 1 st DOB **TD within last 10 years

HEPATITIS B: Date

I do hereby give Guilford Technical Community College permission to notify

My parents/guardian in the event of an emergency.

Student Signature

A. Is there any loss or seriously impaired function of any

paired organ? Yes No

B. Have you any general comments?

C. Recommendations for physical activity (Physical Education, intramural sports, etc.) Unlimited Limited

Explain:

D. Do you have any recommendations regarding the care of this student? Yes No

E. Is this student now under treatment for any medical or emotional condition? Yes No

Physician’s Signature Date of Examination

Print Name

FOR OFFICE USE ONLY

3/17

Financial

Certificate for

International

Applicants

INSTRUCTIONS

Students must be citizens or permanent residents of the United States to qualify for

federal financial aid. International student applicants requesting F-1 immigration

status are also required by United States federal regulations to certify that they have

sufficient funds to pay for all expenses at Guilford Technical Community College for the

entire length of studies. The Certificate of Eligibility Form I-20 will be issued only

after this form has been received with the requested financial documentation

and approved, and you have been offered admission.

All international students should complete the Financial Certificate:

Personal Information (section 1 and 2), including a copy of the passport. The Financial

Certificate and supporting documents must be original copies sent by mail or courier

service. We are not able to accept electronic copies of these documents.

Some international students receive financial assistance from sources outside the

Community College. Consult publications available through your school, the United States

Information Service Library, or the United States Consulate in your country. You may

also wish to investigate possible sources of financial assistance from your government or

organizations in your country. You should begin these inquiries as early as possible. Due

to federal regulations restricting work authorization, most international students should

not expect employment to be a significant means of financial support while studying at

GTCC.

Estimated Costs

Estimated costs are listed below and on the Financial Certificate form. Costs are

“estimated” because there is always the possibility of increases in tuition and fees over

the course of your education, and increases in the cost of living should be anticipated.

Expenses are estimated for one academic year (August through May) for a single student

and do not include transportation between the University and your country:

Tuition and fees $5,757

Required health insurance $1,600

Room/board, books, and

personal expenses $6,800

Estimate for academic year $14, 157

The Financial Certificate and Sources of Support need to indicate your personal

information, including your country of citizenship, and evidence that you and/or whoever

is sponsoring your education has resources set aside to take care of your expenses for at

least one year. An accompanying original, current (within three months) bank statement,

must show funds for one year’s expenses and a letter, signed and dated by a bank official. The

amount should equal $15,000. However, sponsors should certify that funds will be available

for each year of your studies in your program at GTCC. The Financial Certificate,

Sources of Support, sponsor’s letter, bank statements, and signatures must be originals.

The Certificate of Eligibility Form I-20 cannot be issued until the University receives original

documentation.

Financial Certificate: Personal Information

Students not requesting a Form I-20 should complete page one to provide their biographical and immigration information.

.

After you sign the form and submit a copy of your passport, you are done with this form. If you are requesting a Form I-20 F-1 status, please read the following instructions and complete page 3. Certificate of Eligibility Forms I-20 are issued only when all admission procedures have been satisfied. International student applicants requesting F-1 immigration status, including students transferring in F-1 status from another U.S. school, are required by United States federal regulations to certify that they have sufficient funds to pay for all expenses at Guilford Technical Community College for the entire length of studies. Please note, however, that an-nual North Carolina state-mandated tuition increases often occur just prior to registration. In computing your expenses, you should bear in mind that students in Student (F) immigration status will not be authorized to work off-campus except under extraordinary circumstances. Therefore, the applicant should not look to employment, either part-time during the academic year or full-time during the summer, as a significant means of support while at GTCC.

Estimated Costs for 2015–2016

Tuition and fees $5757.00

Required health insurance $1680.00

Room/board, books, and $6800.00

Personal Expenses

Total for Academic Year $14, 157

Please add $12,000 for dependents.

Full Name (please print name as it appears on passport): _____________________________ _______________________ _______________________

family/surname first/given middle

Date of birth (MM/DD/YYYY): _________________ Place of Birth: (city) ____________________ (country) ___________________ Male Female

Current Mailing Address (for all correspondence between January and August 2015; please notify us in writing if there are any changes)

Address: _____________________________________________________________________________ ________________________________________

street address or post office box city

District or province: ________________________________ Country:_____________________________________ Postal Code:______________________

At this address until (MM/DD/YYYY): __________________________

Permanent Foreign Address (students who require a student visa must enter a complete physical address; no post office box numbers will be

accepted)

Address: _____________________________________________________________________________ _________________________________________

street address city

District or province: ________________________________ Country:_____________________________________ Postal Code:______________________

Additional Information

Country of citizenship: ____________________________________________ Country of permanent residence:___________________________________

Are you currently in the U.S.? Yes No If yes, what is your current immigration status? (examples: F-1, H4, Pending Permanent Resident, TD)

________________________________

Do you require a Certificate of Eligibility Form I-20 (for F-1 visas) issued by GTCC? Yes No, I plan to attend GTCC using my current immigration

status. Email Address:_____________________________________________________ (please add nlbynum@gtcc.edu to your safe contact list so we may

contact you with questions)

If you plan on bringing dependents with you to the U.S. in F-2 please add $12,000 to your expense estimates.

I am applying for admission to GTCC for Fall 20____ Spring 20____ Summer I 20____

I am applying as a First-year Transfer Readmitted Student

I expect my program of study to require _____ years.

Applicant’s Signature: ___________________________________________________________________________ Date: __________________________

If you are not requesting a Form I-20 from GTCC and plan to attend school using your current immigration status, you do not need to complete page three or attach any financial documents. After you sign the form and submit a copy of you passport, you are done with this form. If you are requesting a Form I-20 for F-1 status, please read the following instructions and complete page

3. In order to receive a Certificate of Eligibility Form I-20 from GTCC, a prospective student requesting F-1 immigration status must demonstrate that sufficient financial support is available for the entire length of the academic program. Financial documentation (for example, an official award letter or a bank certifica-tion) must be submitted verifying that at least the Total Estimated Costs (as listed above) are immediately available for the first year of your program. On the following page, enter the amount and source(s) of funds available for your first year at GTCC. The total Estimated Costs are subject to increase each academic year.

Note: Please obtain two originals of each type of financial documentation. Send one set of originals with your financial certificate, in order for GTCC to issue the Form I-20. Also, keep one set of originals for yourself because they will be required at the U.S. Embassy or Consulate when you apply for your visa, and they may be required again upon entry to the U.S. during immigration inspection.

Sources of Support

Personal Funds Name of Bank:

___________________________________________________________________________________

A current original bank certification in English that is signed and dated within the last six months by a bank official is required to be submitted with this financial certificate if the student is supported in part or totally by personal funds. Electronic bank statements will not be accepted. The bank certification must demonstrate that the account holder has funds immediately available on deposit for a specific dollar amount.

Parents or Other Personal Sponsors Print name of each parent/sponsor:

____________________________________________________________________________________

A current original bank certification in English that is signed and dated within the last three months by a bank official is required to be submitted with this financial certificate if the student is supported in part or totally by parent, family or other personal sponsor funds. Electronic bank statements will not be accepted. The bank certification must demonstrate that the account holder has funds immediately available on deposit for a specific dollar amount. Parent or other personal sponsors providing funds for this student’s program of study at GTCC must provide a separate signed and dated letter verifying the amount of funds that the sponsor is willing to provide and the number of years those funds will be avail-able to the student. In addition to the bank statement we will also need a letter from the bank.

Example of a sponsor’s letter:

I, (enter full name of sponsor), will support (enter name of student) my (enter relationship to student: son, daughter, friend, employee, etc.), in the amount of (enter total U.S. dollar amount of support avail-able for his/her first year) for his/her first year of study at Guildford Technical Community College and have provided documentation that these funds are available. As well, I understand that the estimated costs of attendance for this student’s program at GTCC l are expected to increase by approximately 10% each year. I pledge that funds in the amount of (enter U.S. dollar amount available per year) will be available to this student per year for a period of (enter number of years sponsor is willing to support student).

(Print full name of sponsor, Signature of sponsor and Date)

Please also read the note on the first page of the Financial Certificate about collecting two originals of each type of financial documentation.

Your Government Print name of agency:______________________________________________________________________________

Attach original, official documentation in English of your award.

GTCC Awards (for example, athletic award)

Type and amount of award:______________________________________________________________________________

If you have applied for funding from the Community College and you receive such an award, a copy of your award letter detailing the amounts awarded must be submitted. Please be aware that if your award does not cover the total estimated costs for the academic year (see page 1), you will be contact-ed to show additional financial support, which may cause a delay in the issuance of your Form I-20 or DS-2019.

Other Please specify: ____________________________________________________________________________________

Enclose a signed affidavit with English translation from authorized person to certify accuracy.

Total Total for the year should be equal to or greater than the cost estimate of US $15, 000 for the first year.

(Please expect approximately a increase each year in the stated amount. All sources of support (or com-bination thereof) should guarantee support for the entire length of the student’s academic program.)

Amounts Available (in U.S. dollars)

Enter the total amount of money you expect to have when you arrive at this Community College:$__________________________________ (U.S. dollars)

Student’s Financial Pledge I certify that the information on this Financial Certificate and any supporting documentation is true and accurate. I have read the information here provid-ed and understand and agree to my financial obligation to GTCC including the requirement that I shall maintain the required health insurance for myself and all accompanying family members for the duration of my studies at the Community College. I understand that by signing this document I am bound to uphold the rights and responsibilities as defined under the university honor code (as defined here: gtcc.edu). I understand that any false information pro-vided on this form is a violation of the honor code to which I am accountable.

Applicant’s Signature: ________________________________________________________________________________ Date: ______________________

OMB No. 1615-0014

Form I-134, Affidavit of Support Department of Homeland Security

U.S. Citizenship and Immigration Services

(Answer all items. Type or print in black ink.)

I, (Name)

residing at (Street Number and Name)

-

(City) (State) (Zip Code if in U.S.) (Country)

certify under penalty of perjury under U.S. law, that:

1. I was born on in (Date-mm/dd/yyyy) (City) (State) (Country)

If you are not a U.S. citizen based on your birth in the United States, or a non-citizen U.S. national based on your birth in American Samoa (including

Swains Island), answer the following as appropriate:

a. If a U.S.citizen through naturalization, give Certificate of Naturalization number

b. If a U.S. citizen through parent(s) or marriage, give Certificate of Citizenship number

c. If U.S. citizenship was derived by some other method, attach a statement of explanation.

d. If a Lawful Permanent Resident of the United States, give A-Number

e. If a lawfully admitted nonimmigrant, give Form I-94, Arrival-Departure Record, number

2. I am years of age and have resided in the United States since (Date-mm/dd/yyyy)

3. This affidavit is executed on behalf of the following person:

Name (Family Name) (First Name) (Middle Name) Gender Age

Citizen of (Country) Marital Status Relationship to Sponsor

Presently resides at (Street Number and Name) (City) (State) (Country)

Name of spouse and children accompanying or following to join person:

Spouse Gender Age Child Gender Age

Child Gender Age Child Gender Age

Child Gender Age Child Gender Age

4. This affidavit is made by me for the purpose of assuring the U.S. Government that the person(s) named in item (3) will not become a public

charge in the United States.

5. I am willing and able to receive, maintain, and support the person(s) named in item 3. I am ready and willing to deposit a bond, if necessary, to

guarantee that such person(s) will not become a public charge during his or her stay in the United States, or to guarantee that the above named

person(s) will maintain his or her nonimmigrant status, if admitted temporarily, and will depart prior to the expiration of his or her authorized stay

in the United States.

6. I understand that:

a. Form I-134 is an “undertaking” under section 213 of the Immigration and Nationality Act, and I may be sued if the person(s) named in item 3

becomes a public charge after admission to the United States;

b. Form I-134 may be made available to any Federal, State, or local agency that may receive an application from the person(s) named in item 3

for Food Stamps, Supplemental Security Income, or Temporary Assistance to Needy Families; and

c. If the person(s) named in item 3 does apply for Food Stamps, Supplemental Security Income, or Temporary Assistance for Needy Families,

my own income and assets may be considered in deciding the person's application. How long my income and assets may be attributed to the

person(s) named in item 3 is determined under the statutes and rules governing each specific program.

Form I-134 (Rev. 05/25/11) Y

7. I am employed as or engaged in the business of with (Type of Business)

at

(Name of Concern)

-

(Street Number and Name (City) (State) (Zip Code)

I derive an annual income of: (If self-employed, I have attached a copy of my last income tax return or

report of commercial rating concern which I certify to be true and correct to the best of my knowledge

and belief. See instructions for nature of evidence of net worth to be submitted.) $

I have on deposit in savings banks in the United States: $

I have other personal property, the reasonable value of which is: $

I have stocks and bonds with the following market value, as indicated on the attached list, which I certify

to be true and correct to the best of my knowledge and belief: $

I have life insurance in the sum of: $

With a cash surrender value of: $

I own real estate valued at: $

With mortgage(s) or other encumbrance(s) thereon amounting to: $

Which is located at:

(Street Number and Name)

(City) (State)

-

(Zip Code)

8. The following persons are dependent upon me for support: (Check the box in the appropriate column to indicate whether the person named is

wholly or partially dependent upon you for support.)

Name of Person Wholly Dependent Partially Dependent Age Relationship to Me

9. I have previously submitted affidavit(s) of support for the following person(s). If none, state "None".

Name of Person

Date submitted

10. I have submitted a visa petition(s) to U.S. Citizenship and Immigration Services on behalf of the following person(s). If none, state "None".

Name of Person Relationship Date submitted

11. I intend

do not intend to make specific contributions to the support of the person(s) named in item 3.

(If you check "intend," indicate the exact nature and duration of the contributions. For example, if you intend to furnish room and board, state

for how long and, if money, state the amount in U.S. dollars and whether it is to be given in a lump sum, weekly or monthly, and for how long.

Oath or Affirmation of Sponsor

I acknowledge that I have read "Sponsor and Alien Liability" on Page 2 of the instructions for this form, and am aware of my responsibilities

as a sponsor under the Social Security Act, as amended, and the Food Stamp Act, as amended.

I certify under penalty of perjury under United States law that I know the contents of this affidavit signed by me and that the statements are

true and correct.

Signature of Sponsor Date

Form I-134 (Rev. 05/25/11) Y Page 2

Universal Bank

__________________________________________________________

August 15, 2017

To Whom It May Concern:

John Doe has an active account with Universal Bank. His account

has a current balance of $35,350. The account has been open for at

least 90 days. If you have any other questions or concerns, please

feel free to contact me at 336.555.6666.

Sincerely,

Jane Doe Jane Doe

Customer Service Department