Second Year Source of Funds (U.S. Dollars Only)
Student’s Personal Funds
Funds from Family
Funds from another source (please specify)
TOTAL
Third Year Source of Funds (U.S. Dollars Only)
Student’s Personal Funds
Funds from Family
Funds from another source (please specify)
TOTAL
Fourth Year Source of Funds (U.S. Dollars Only)
Student’s Personal Funds
Funds from Family
Funds from another source (please specify)
TOTAL
______
$_____
$_____
______ $___
$_____
$ ___
$_____
CERTIFICATION
This is to certify that I have read the information furnished by the applicant on this form and that it is true and accurate. The above funds are available.
BANK OFFICIAL
Bank Official's SignatureDate
Official Title or PositionPhone Number
Complete Street Address
CityProvince/StateCountryZip/Postal Code
Notary SignatureFAMILY OR FRIEND
Family and/or Friend(s) SignatureDate
RelationPhone Number
Complete Street Address
CityProvince/StateCountryZip/Postal Code
I certify that the above information is true and correct; I also understand that falsifying this document could result in my admissions to Kentucky State University being rescinded.
Signature of Applicant
Date
It is the policy of Kentucky State University not to discriminate against any individual in its educational program, activities, or employment on the basis of race, color, national origin, sex, disability, veteran status, age, religion or marital status.