Program Extension Request Form
To be completed by the student
This request form is to extend F-1 or J-1 stay if you will not complete your current degree by the date indicated on your
Form I-20 or Form DS-2019. This form must be completed by the student and the academic advisor. It must be
returned to our office together with the financial proof sufficient enough for the period being extended. Upon the
receipt of all of the documents, the request will be processed accordingly.
Student’s Name: ____________________________________
LAST (Family)
_________________________________________
FIRST (Given)
Student ID#: Z ___ ___ ___ ___ ___ ___ ___ SEVIS ID#: N ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Email (other than z-id):____________________________________
Level of Study:
Phone: ___________________________________
 Bachelor’s  Master’s  Ph.D. Major/Department: ____________________________________
To be completed by the Academic Advisor or Graduate Advisor
International students in F-1 or J-1 status are required to maintain a full course load during each Fall and Spring
semester, and to make satisfactory progress toward degree completion. The student named above requests to extend
his/her academic program. In order to assist the student in complying with the U.S. immigration regulations, we will
greatly appreciate if you can provide the following information.
Reason for change in expected complete date:
 Student must complete (_______) credit hours to satisfy requirements
 Student has completed all course work and is currently working on thesis/dissertation.
Additional Comments: _____________________________________________________________________________
________________________________________________________________________________________________
Student is expected to complete his/her educational objective by: ____________________________________________
I understand that the information provided on this form will be used to determine this student’s eligibility for an immigration benefit. My signature
certifies that I am familiar with this student’s academic program and that I am authorized by my department to make this recommendation.
Advisor’s name: ________________________________________________
Phone: __________________________
Signature: _____________________________________________________
Date: ____________________________
May 2015
Program Extension Request Form
STATEMENT OF FINANCIAL ABILITY
Indicate the funding sources used to support you (and if applicable your dependents); check all that apply:
 Student’s personal bank statement(s) (it must be within the last 6 months)
 Financial sponsor’s bank statement(s) (it must be within the last 6 months) AND a support letter signed by
the financial sponsor
 Letter of Graduate Assistantship from a Department(s)
 Proof of Tuition Waiver from the school
 Proof of scholarship(s) from our school or any other organization
 Others (please specify): ____________________________________________________________
I certify that I will be responsible for the total cost for each year of study at Northern Illinois University, including
expenses associated with dependents (if applicable).
_________________________________
Student Signature
_______________________
Date
ESTIMATED EXPENSES FOR AN ACADEMIC YEAR (Tuition & fees plus Living Expenses)
Undergraduate
Tuition & Fees
Living Expenses
Total
Graduate
Tuition & Fees
Living Expenses
Total
PhD 799 Level ONLY
Tuition & Fees
Living Expenses
Total
Dependents
Child
Spouse
One Semester
Two Semesters
$11675
$5750
$17425
$23350
$11500
$34850
$8755
$5750
$14505
$17511
$11500
$29011
$2585
$5750
$8335
$5170
$11500
$16670
$3250
$2750
$6500
$5500
Please fully complete both sides of this request form and attach any supporting documentation before submitting to
International Student and Faculty Office (ISFO).
Please allow for 2-3 business days for processing.
May 2015