===== PAGE 1 =====
# KENTUCKY STATE UNIVERSITY Declaration & Certification of Finances (For International Students Only)
A Certificate of Eligibility (form I-20 or DSP-66) will not be authorized until this form is completed and returned. When all admissions criteria have been appropriately met for Graduate Studies, a copy of this form will be attached to the Certificate of Eligibility. Both must be shown to the U.S. Consulate for issuance of the Visa.
*ESTIMATED GENERAL EXPENSES FOR THE GRADUATE STUDENT * 2009-2010 ACADEMIC YEAR (FALL AND SPRING SEMESTERS)
| Tuition @811 per credit hour x 9 credit hours or Full-Time | 811 x 9 x 2(semesters) | 14,598 per year |
| Books and Supplies | | 1,200 per year |
| Personal Expenses 3,500 deposit +2,000 for 2 semesters | | 5,500 per year |
| Miscellaneous (Includes Transportation) | | 1,310 per year |
| TOTAL COST PER ACADEMIC YEAR | | 19,108 |
| *Travel Cost Will Vary |
A confirmation deposit of $3,500 (US) is sent to the Office of Graduate Admissions. A student may use a maximum of 65% of the $3,500 deposit to pay the first semester's tuition and fees. The balance will remain on account until the student graduates or withdraws from Kentucky State University.
**ALL FEES SUBJECT TO CHANGE WITHOUT NOTICE**
| Family Name | First Name | Middle Name |
| Complete Street Address |
| Complete Street Address (cont'd) |
| City | Province | Country | Zip Code |
| Major | | Date of Expected Graduation |
| Birth Date | | Country of Birth |
| Intended enrollment at KSU | Fall | Spring | Summer | Year |
## OFFICIAL VERIFICATION OF SOURCES OF FUNDS AND AMOUNTS
#### First Year Source of Funds (U.S. Dollars Only)
| a) | $3,500 initial deposit | $ |
| b) | Student’s Personal Funds | $ |
| c) | Funds from Family | $ |
| d) | Funds from another source (please specify) | < /td > < /tr > < /table > TOTAL_____
===== PAGE 2 =====
Second Year Source of Funds (U.S. Dollars Only)
a) Student’s Personal Funds
b) Funds from Family
c) Funds from another source (please specify)
TOTAL
Third Year Source of Funds (U.S. Dollars Only)
a) Student’s Personal Funds
b) Funds from Family
c) Funds from another source (please specify)
## TOTAL
Fourth Year Source of Funds (U.S. Dollars Only)
a) Student’s Personal Funds
b) Funds from Family
c) 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 Signature | | Date | | | Official Title or Position | | Phone Number | | | Complete Street Address | | City | Province/State | Country | Zip/Postal Code | | Notary Signature | FAMILY OR FRIEND | | Family and/or Friend(s) Signature | | Date | | | Relation | | Phone Number | | | Complete Street Address | | City | Province/State | Country | Zip/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.
|