International Student Financial Affidavit - University at Albany

UNIVERSITY AT ALBANY
INTERNATIONAL STUDENT FINANCIAL AFFIDAVIT
Please read the appropriate instructions prior to completing this form.
Part 1
1. Name of Applicant: Mr./Ms.
2. Permanent Address:
3. University ID number (if known): - - Date of Birth (mm/dd/yr) / /
4. Department and degree applying to:
5. Current U.S. visa you hold (if any): _______________________________
Part 2
Complete each relevant item below. Sign and date the form at (C).
Enter the amount of assured support available in U.S. dollars for each year of study.
Source of Funds Year 1 Year 2 Year 3 Year 4 Required Verification
Personal Savings
Name of Bank:
$ $ $ $ 1. Bank Statement
2. Complete (A) and (C)
below.
Relative/Sponsor
Names:
$ $ $ $ 1. Bank Statement
2. Complete (B) and (C)
below.
Scholarship/Grant
awarded by:
$ $ $ $ 1. Official award letter.
See instructions.
2. Complete (C) below.
TOTALS
$ $ $ $
VERIFICATION
A. This is to certify that the funds indicated above are on deposit or are being held in the name of the applicant named above
at the savings institution named below. Verification of amounts is without liability for the bank or its officials. Attach
separate statement of accounts with official signature/seal.
Name of Bank: Date:
Bank Officer Name and Title:
Bank Officer Signature:
B. This is to certify that the undersigned has agreed to provide the funds indicated above to the applicant for the purpose of
full-time study at the University at Albany and is submitting bank statements indicating the availability of these funds. It
is further understood that the University might not provide any financial assistance to the applicant and the funds must be
provided for the duration of the applicant's course of study. If the commitment is not met, the student may be subject to
dismissal.
Sponsor: Relationship to applicant:
Signature: Date:
C. This certifies that the information given on this form is accurate to the best of my knowledge. I am fully aware that false
or misleading statements may result in denial of admission or cancellation of registration. By signing below, I fully
understand that I might not receive financial assistance from the University at Albany during my first year of study and
that the University is under no obligation to provide funds to me for future terms or in the event of an emergency.
Applicant's Signature: Date:
Page 1/3
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