Dependent – Add / Delete Clear Form

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International Programs and Services
200 Administration Building
1400 Townsend Drive
Houghton, Michigan 49931‐1295
Tel: (906) 487‐2160
Email: [email protected]
Clear Form
Dependent – Add / Delete
You will need to request a new I‐20 or DS-2019 when you add a dependent, or when a dependent is dropped because of age, change of status, etc. This form can be emailed to International Programs and Services (IPS). Student or Visiting Scholar Information
Last Name First Name Email Michigan Tech ID M @mtu.edu Action Requested
add dependent to I‐20 or DS-2019  You must attach a copy of the picture page of the passport for each dependent being added.
 You must attach proof of finances (in addition to your own as a student) for each dependent being
added: $4000 for a spouse, $2000 for each child.
delete dependent from I‐20 or
DS-2019 Reason dependent is being deleted Dependent Information
Last Name First Name Middle Name Spouse's Email:
Relationship Spouse Child Gender Date of Birth Male Female City of Birth month day year Country of Birth Country of Citizenship Home Address (This is the address in the home country. A Post Office Box address is not acceptable) Street Province/Territory City Country Postal Code Student Signature: ______________________________________Date:____________________________ Michigan Technological University is an Equal Opportunity Educational Institution/Equal Opportunity Employer, which includes providing equal opportunity for protected veterans and individuals with disability. Dependent – Add / Delete
Please use this page if you are adding more than one dependent Dependent Information
Last Name First Name Relationship Child Gender Date of Birth Middle Name Male Female City of Birth month day year Country of Birth Country of Citizenship Home Address (This is the address in the home country. A Post Office Box address is not acceptable) Street Province/Territory City Country Postal Code Last Name First Name Relationship Child Gender Date of Birth Middle Name Male Female City of Birth month day year Country of Birth Country of Citizenship Home Address (This is the address in the home country. A Post Office Box address is not acceptable) Street Province/Territory City Country Postal Code Student Signature: ______________________________________Date:____________________________ Michigan Technological University is an Equal Opportunity Educational Institution/Equal Opportunity Employer, which includes providing equal opportunity for protected veterans and individuals with disability. 
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