CERTIFICATION OF FINANCIAL RESPONSIBILITY (CFR)
Exchange Students
Sam Houston State University / Office of International Programs
**This form is necessary for the preparation of a Form I-20/DS-2019 for Sam Houston State
University**
This form is valid for ONE YEAR from date of signature. The appropriate immigration document will be
issued AFTER you have: (1) been officially admitted to Sam Houston State University AND (2)
submitted this form along with proof of financial support for your studies.
Questions about the completion of this form may be directed to ugrad.intl@shsu.edu or
grad.intl@shsu.edu
INSTRUCTIONS:
Upload this completed form (in PDF format)
Print a copy
Please be prepared to show this documentation to the United States Consulate upon interviewing for
your visa.
Please note: ALL statements of support must be in English.
**** STUDENT INFORMATION ****
SamID: ____________________________________
Type of Visa Desired:
F-1 (I-20)
J-1 (DS-2019)
NAME AS LISTED IN YOUR PASSPORT:
_____________________________________________________________________________
(Family/Last)
(First)
(Middle)
Gender:
Male
Female
DATE OF BIRTH (Month/Day/Year): ______________________
City & Country of Birth: _______________________________________________________
Country of Citizenship: ___________________________
Email Address: _______________________________________
Admission for Semester /Year: Fall (______) Spring (______)
**Exchange Students: check all semesters you will be enrolled
Degree Level Sought:
Bachelor
Master
Summer (______)
Ph.D. / Major: ________________________
If J-1, indicate your occupation or level of studies (e.g. bachelor, master, doctoral):
_________________________________________________________________
Will you be transferring from another US institution? ____ Yes ____ No
If yes, Institution Name: __________________________________________________
Address where immigration documents should be sent:
_________________________________________________
_________________________________________________
_________________________________________________
Documents to be sent outside the U.S. will be shipped after student registers and pays through EShipGlobal: https://study.eshipglobal.com/home/?q=s
**** DEPENDENT INFORMATION ****
List the following information for all dependents you plan to bring with you (including your future spouse,
if you plan to marry before traveling to the university). The statement of financial support must include
sufficient support for any dependents who will accompany you or plan to join you at a later date. Please
not, a dependent is defined as a spouse or child.
Name (Last, First); Relationship; Date of Birth (mm/dd/yyyy); City & Country of Birth; Citizenship;
Gender.
1) ___________________________________________________________________________
2) ___________________________________________________________________________
3) ___________________________________________________________________________
4) ___________________________________________________________________________
5) ___________________________________________________________________________
I certify that the above information provided on this form is correct and complete. If any of the
information changes prior to my enrollment at Sam Houston State University, I will immediately notify
OIP. I understand that making false or fraudulent statements within this Certification of Financial
Responsibility may result in disciplinary action.
Applicant's Signature: ____________________________________ Date:______________
NAME: ______________________________________________________________________
**** FINANCIAL INFORMATION ****
Estimates include tuition and fees for one academic year (exchange students do not pay SHSU’s tuition
& fees) and 12 months of living expenses. They do not include summer tuition. When computing your
expenses, remember that you should not look to employment as a means of support unless an offer of an
academic appointment (teaching or research assistantship) accompanies admission to a graduate
department. Financial aid is generally not available to new international students, and financial assistance
to continuing students is extremely limited.
International students enrolled at SHSU are required to have medical insurance. For SHSU’s medical
insurance, students studying in the fall semester will have a $566 charge placed on their student account.
For students studying in the spring semester, a $900 charge will be placed on their student account (for
spring & summer). For students staying a year, a $1,453 charge will be placed on their student account.
Dependents of J-1 exchange visitors are required to have medical insurance but it is advisable for all
dependents to also have medical insurance. To apply for a waiver if students qualify to use their own
medical insurance from their home country, go to: https://shsu.myahpcare.com/waiver
Please determine your estimated expenses [per academic year (Fall/Spring)] as published by the
Bursar’s Office:
http://www.shsu.edu/~csh_www/financial.html
SOURCE OF FINANCIAL SUPPORT
Personal and/or family savings (a bank official's signature below or an attached bank letter/bank
statement is required if the applicant will be supported in whole or part by personal family savings).
Sam Houston State University Assistantship/Fellowship/Scholarship (upload copy of award letter
from department)
Government/Other Sponsor (print name of agency and attach signed copy of letter certifying
sponsorship):___________________________________________
Other (Specify and attach a signed certification):
______________________________________________________________________________
BANK AND/OR SPONSOR'S OFFICIAL CERTIFICATION OF SOURCES OF FUNDS
I, __________________________ (name), guarantee that the sum amount of $ __________USD will be
available to the above named student for the first academic year at Sam Houston State University. A
comparable amount of money will be available for the duration of the student’s program. I understand that
this statement is being used for the purpose of issuing a U.S. government document.
Parent/Sponsor's Signature: ________________________________
Date: _______________
Relationship of Sponsor to Applicant:
____________________________________________________________________________
This is to certify that I have read the information given by the applicant on this form, that it is true and
accurate, and that the funds are available:
Bank Official's Signature: ____________________________________ Date: _____________
Bank Official's Name (PRINT): _________________________ Title: ____________________
Name and Address of Bank: ______________________________________________________
______________________________________________________