I-20, Certificate of Eligibility for Nonimmigrant Student Status

SEVIS ID: N0004720633

SCHOOL INFORMATION

PROGRAM OF STUDY

FINANCIALS

REMARKS

SCHOOL ATTESTATION

STUDENT ATTESTATION

Department of Homeland Security I-20, Certificate of Eligibility for Nonimmigrant Student Status

U.S. Immigration and Customs Enforcement

OMB NO. 1653-0038

SURNAME/PRIMARY NAME

Sample

GIVEN NAME

Student

Class of Admission

PREFERRED NAME

Student Sample, II

PASSPORT NAME

F-1

COUNTRY OF BIRTH

LAOS

COUNTRY OF CITIZENSHIP

LAOS

DATE OF BIRTH

04 MAY 1995

ADMISSION NUMBER

ACADEMIC AND

LANGUAGE

FORM ISSUE REASON

CONTINUED ATTENDANCE

LEGACY NAME

SCHOOL NAME

SEVP School for Advanced SEVIS Studies

SCHOOL ADDRESS

9002 Nancy Lane, Ft. Washington, MD 20744

SCHOOL OFFICIAL TO CONTACT UPON ARRIVAL

Helene Robertson

PDSO

SCHOOL CODE AND APPROVAL DATE

BAL214F44444000

03 APRIL 2015

EDUCATION LEVEL

BACHELOR'S

MAJOR 1

History and Philosophy of Science

and Technology 54.0104

MAJOR 2

None 00.0000

PROGRAM ENGLISH PROFICIENCY

Required

ENGLISH PROFICIENCY NOTES

Student is proficient

EARLIEST ADMISSION DATE

04 APRIL 2016

START OF CLASSES

01 JUNE 2016

PROGRAM START/END DATE

04 MAY 2016 - 30 MAY 2020

ESTIMATED AVERAGE COSTS FOR: 9 MONTHS STUDENT'S FUNDING FOR: 9 MONTHS

Tuition and Fees $ 15,000 Personal Funds $ 19,000

Living Expenses $ 4,000 Funds From This School $

Expenses of Dependents (0) $ 0 Funds From Another Source $

Other $ 0 On-Campus Employment $

TOTAL $ 19,000 TOTAL $ 19,000

I certify under penalty of perjury that all information provided above was entered before I signed this form and is true and correct. I executed this form in the United

States after review and evaluation in the United States by me or other officials of the school of the student's application, transcripts, or other records of courses taken

and proof of financial responsibility, which were received at the school prior to the execution of this form. The school has determined that the above named student's

qualifications meet all standards for admission to the school and the student will be required to pursue a full program of study as defined by 8 CFR 214.2(f)(6). I am a

designated school official of the above named school and am authorized to issue this form.

X DATE ISSUED PLACE ISSUED

SIGNATURE OF: Helene Robertson, PDSO

04 May 2016 Ft. Washington,MD

I have read and agreed to comply with the terms and conditions of my admission and those of any extension of stay. I certify that all information provided on this form

refers specifically to me and is true and correct to the best of my knowledge. I certify that I seek to enter or remain in the United States temporarily, and solely for the

purpose of pursuing a full program of study at the school named above. I also authorize the named school to release any information from my records needed by DHS

pursuant to 8 CFR 214.3(g) to determine my nonimmigrant status. Parent or guardian, and student, must sign if student is under 18.

SIGNATURE OF: Student Sample

DATE

NAME OF PARENT OR GUARDIAN SIGNATURE ADDRESS (city/state or province/country) DATE

ICE Form I-20 A-B (3/31/2018) Page 1 of

EMPLOYMENT AUTHORIZATIONS

EMPLOYER INFORMATION

CHANGE OF STATUS/CAP-GAP EXTENSION

AUTHORIZED REDUCED COURSE LOAD

CURRENT SESSION DATES

TRAVEL ENDORSEMENT

Department of Homeland Security I-20, Certificate of Eligibility for Nonimmigrant Student Status

U.S. Immigration and Customs Enforcement

OMB NO. 1653-0038

SEVIS ID: N0004720633 (F-1) NAME: Student Sample

TYPE FULL/PART-TIME STATUS START DATE END DATE

CPT PART TIME APPROVED 01 JULY 2016 15 JULY 2016

TYPE AUTHORIZATION DATES

CPT 01 JULY 2016 - 15 JULY 2016

EMPLOYER NAME START DATE END DATE CITY & STATE

SEVP applied labs 01 JULY 2016 15 JULY 2016 Arlington, VA

CURRENT SESSION START DATE CURRENT SESSION END DATE

01 JUNE 2016 30 JUNE 2016

This page, when properly endorsed, may be used for re-entry of the student to attend the same school after a temporary absence from the United States. Each

endorsement is valid for one year.

SCHOOL OFFICIAL TITLE SIGNATURE DATE ISSUED PLACE ISSUED

ICE Form I-20 A-B (3/31/2018) Page 2 of

Department of Homeland Security I-20, Certificate of Eligibility for Nonimmigrant Student Status

U.S. Immigration and Customs Enforcement

OMB NO. 1653-0038

INSTRUCTIONS TO STUDENTS

STUDENT ATTESTATION. You should read everything on this page

carefully. Be sure that you understand the terms and conditions concerning your

admission and stay in the United States as a nonimmigrant student before signing

the student attestation on page 1 of the Form I-20 A-B. The law provides severe

penalties for knowingly and willfully falsifying or concealing a material fact, or

using any false document in the submission of this form.

FORM I-20. The Form I-20 (this form) is the primary document to show that

you have been admitted to school in the United States and that you are

authorized to apply for admission to the United States in F-1 class of admission.

You must have your Form I-20 with you at all times. If you lose your Form I-20,

you must request a new one from your designated school official (DSO) at the

school named on your Form I-20.

VISA APPLICATION. You must give this Form I-20 to the U.S. consular

officer at the time you apply for a visa (unless you are exempt from visa

requirements). If you have a Form I-20 from more than one school, be sure to

present the Form I-20 for the school you plan to attend. Your visa will include

the name of that school, and you must attend that school upon entering the

United States. You must also provide evidence of support for tuition and fees

and living expenses while you are in the United States.

ADMISSION. When you enter the United States, you must present the

following documents to the officer at the port of entry: 1) a Form I-20; 2) a valid

F-1 visa(unless you are exempt from visa requirements); 3) a valid passport; and

4) evidence of support for tuition and fees and living expenses while you are in

the United States. The agent should return all documents to you before you leave

the inspection area.

REPORT TO SCHOOL NAMED ON YOUR FORM I-20 AND VISA.

Upon your first entry to the United States, you must report to the DSO at the

school named on your Form I-20 and your F-1 visa (unless you are exempt from

visa requirements). If you decide to attend another school before you enter the

United States, you must present a Form I-20 from the new school to a U.S.

consular officer for a new F-1 visa that names the new school. Failure to enroll

in the school, by the program start date on your Form I-20 may result in the loss

of your student status and subject you to deportation.

EMPLOYMENT. Unlawful employment in the United States is a reason for

terminating your F-1 status and deporting you from the United States. You may

be employed on campus at your school. You may be employed off-campus in

curricular practical training (CPT) if you have written permission from your

DSO. You may apply to U.S. Citizenship and Immigration Services (USCIS) for

off-campus employment authorization in three circumstances: 1) employment

with an international organization; 2) severe and unexpected economic hardship;

and 3) optional practical training (OPT) related to your degree. You must have

written authorization from USCIS before you begin work. Contact your DSO for

details. Your spouse or child (F-2 classification) may not work in the United

States

PERIOD OF STAY. You may remain in the United States while taking a full

course of study or during authorized employment after your program. F-1 status

ends and you are required to leave the United States on the earliest of the

following dates: 1) the program end date on your Form I-20 plus 60 days; 2) the

end date of your OPT plus 60 days; or 3) the termination of your program for

any other reason. Contact your DSO for details.

EXTENSION OF PROGRAM. If you cannot complete the education program

by the program end date on page 1 of your Form I-20, you should contact your

DSO at least 15 days before the program end date to request an extension.

SCHOOL TRANSFER. To transfer schools, first notify the DSO at the school

you are attending of your plan to transfer, then obtain a Form I-20 from the DSO

at the school you plan to attend. Return the Form I-20 for the new school to the

DSO at that school within 15 days after beginning attendance at the new school.

The DSO will then report the transfer to the Department of Homeland Security

(DHS). You must enroll in the new school at the next session start date. The

DSO at the new school must update your registration in SEVIS.

NOTICE OF ADDRESS. When you arrive in the United States, you must

report your U.S. address to your DSO. If you move, you must notify your DSO

of your new address within 10 days of the change of address. The DSO will

update SEVIS with your new address.

REENTRY. F-1 students may leave the United States and return within a

period of five months.To return, you must have: 1) a valid passport; 2) a valid F-

1 student visa (unless you are exempt from visa requirements); and 3) your Form

I-20, page 2, properly endorsed for reentry by your DSO. If you have been out of

the United States for more than five months, contact your DSO

AUTHORIZATION TO RELEASE INFORMATION BY SCHOOL. DHS

requires your school to provide DHS with your name, country of birth, current

address, immigration status, and certain other information on a regular basis or

upon request. Your signature on the Form I-20 authorizes the named school to

release such information from your records.

PENALTY. To maintain your nonimmigrant student status, you must: 1)

remain a full-time student at your authorized school; 2) engage only in

authorized employment; and 3) keep your passport valid. Failure to comply with

these regulations will result in the loss of your student status and subject you to

deportation.

INSTRUCTIONS TO SCHOOLS

Failure to comply with 8 CFR 214.3(k) and 8 CFR 214.4 when issuing Forms I-

20 will subject you and your school to criminal prosecution. If you issue this

form improperly, provide false information, or fail to submit required reports,

DHS may withdraw its certification of your school for attendance by

nonimmigrant students.

ISSUANCE OF FORM I-20. DSOs may issue a Form I-20 for any

nonimmigrant your school has accepted for a full course of study if that person:

1) plans to apply to enter the United States in F-1 status; 2) is in the United

States as an F-1 nonimmigrant and plans to transfer to your school; or 3) is in the

United States and will apply to change nonimmigrant status to F-1. DSOs may

also issue the Form I-20 to the spouse or child (under the age of 21) of an F-1

student to use to enter or remain in the United States as an F-2 dependent. DSOs

must sign where indicated at the bottom of page 1 of the Form I-20 to attest that

the form is completed and issued in accordance with regulations.

ENDORSEMENT OF PAGE 2 FOR REENTRY. If there have been no

substantive changes in information, DSOs may endorse page 2 of the Form I-20

for the student and/or the F-2 dependents to reenter the United States. If there

have been substantive changes, the DSO should issue and sign a new Form I-20

that includes those changes.

RECORDKEEPING. DHS may request information concerning the student's

immigration status for various reasons. DSOs should retain all evidence of

academic ability and financial resources on which admission was based, until

SEVIS shows the student's record completed or terminated.

AUTHORITY FOR COLLECTING INFORMATION. Authority for

collecting the information on this and related student forms is contained in 8

U.S.C. 1101 and 1184. The Department of State and DHS use this information to

determine eligibility for the benefits requested.The law provides severe penalties

for knowingly and willfully falsifying or concealing a material fact, or using any

false document in the submission of this form.

REPORTING BURDEN. U.S. Immigration and Customs Enforcement collects

this information as part of its agency mission under the Department of Homeland

Security. The estimated average time to review the instructions, search existing

data sources, gather and maintain the needed data, and complete and review the

collection of information is 30 minutes (.50 hours) per response. An agency may

not conduct or sponsor, and a person is not required to respond to an information

collection unless a form displays a currently valid OMB Control number. Send

comments regarding this burden estimate or any other aspect of this collection of

information, including suggestions for reducing this burden, to: Office of the

Chief Information Officer/Forms Management Branch, U.S. Immigration and

Customs Enforcement. 801 I Street NW Stop 5800, Washington, DC 20536-

5800. Do not send the form to this address.

ICE Form I-20 A-B (3/31/2018) Page 3 of