サンプル - Financial Support (PDF: 161KB)

New York Business Institute
124 E 40th St, Suite 801, New York, NY 10016
p 212.922.1000 | f 212.922.0796 | www.nybi.org | [email protected]
Financial Support Form (財政サポートフォーム)
Sponsor スポンサー
Last name (surname) 姓
Middle initial
First name (given) 名
Matsui
Chichira
Street and Apt. #町丁名、番地、マンション名、住戸番号
123 Yamaguchi-cho
City 市町村
State/Province 県
Zip 郵便番号
Country 国
Nomi
Ishikawa
929-0000
Japan
Relationship to student 関係
XOther Father
Self
本人
その他
Phone 電話番号
e-mail メールアドレス
(0761) 22-1234
[email protected]
Student 生徒
Last name (surname) 姓
Middle initial
First name (given) 名
Matsui
H
Godzilla
Country of birth 出生国
Date of birth 生年月日
Japan
Month
Country of citizenship 国籍
6
/ 12
/ Day
/ 1974
/ Year
Marital Status 婚姻
 Single
 Married
X
独身
Japan
既婚
Gender 性別
 Male
X
 Female
 Divorced
 Widowed
離婚
死別
Street and Apt. # 町丁名、番地、マンション名、住戸番号
123 Yamaguchi-cho
City 市町村
State/Province 県
Zip 郵便番号
Country 国
Nomi
Ishikawa
929-0000
Japan
Phone 電話番号
e-mail メールアドレス
(0761) 22-5555
[email protected]
Name of spouse and children accompany or following to join student. 同行する家族
Last name 姓
First name 名
Date of birth 生年月日
Month
Last name 姓
First name 名
First name 名
First name 名
Page 1
/
/ Day
Relationship to you 続柄
/
/ Year
Date of birth 生年月日
Month
Financial Support Form (11/08)
/
/ Day
Relationship to you 続柄
/
/ Year
Date of birth 生年月日
Month
Last name 姓
/
/ Day
Relationship to you 続柄
/
/ Year
Date of birth 生年月日
Month
Last name 姓
/
/ Day
Relationship to you 続柄
/
/ Year
www.nybi.org
Tuition, cost and expenses 授業料、支出、滞在費用
The financial support includes all expenses such as tuition, books, fees, living, and medical expenses for the whole duration of
my/our/their stay in the United States. 財政サポートは授業料、教科書、諸費用、生活費、医療費等滞在中すべての費用を含みます。
Based on the duration and accompanying dependents, this cost is estimated at: 滞在期間と同行者を考慮した費用
USD
＄12,300
( refer to the Tuition, cost and expenses worksheet 下記の算出表参照)
Funding Sources 財源
 I have on deposit in savings of
X
USD
＄15、555
金融機関に預金がある場合
預金額ドル
* Attach a bank statement that is less than 6 months old. 6 ヶ月以内の銀行の残高証明(英文)を添付)
 I am employed by
雇用主が証明を出せる場合
with the position of
会社･組織名
役職
at
with an annual income of USD
.
会社住所
年収ドル
* Attach a letter from the employer stating title, and income, or tax return if self employed. 雇用主からの役職と収入を証明する手紙か、
自営業の場合は確定申告を添付 (英文)
 I have other assets
with the market value of USD
他の資産がある場合
株、債権、生命保険など
* Attach a statement that is less than 6 months old. 6 ヶ月以内の残高証明(英文)を添付
評価額ドル
I affirm that the contents of this financial support document are true and correct.
I also attest that the student and the family member named above will not become a public charge in the United States.
Documents verifying my financial support accompany this form.
この書類に記載されていることが正しいことを確約します。また生徒とその家族が米国社会の負担にならないことを保証します。私の財政
サポートを証明する書類を添付します。
Chichira Matsui
11
Signature of Sponsor スポンサーサイン
/
5
/
2008
Date (Month/Day/Year)
Tuition, Cost, and Expenses Worksheet 授業料、支出、滞在費用算出表
Total support must be equivalent to estimated expenses checked below: ここで計算される支出と同額以上の証明が必要です。
I need a student (M-1) visa for
 3 months
Tuition, Books, Reg. fee 授業料、本等
Living Expenses 生活費
X 6 months
$3,900
$2,400
 9 months
$7,500
$4,800
 12 months
$11,000
$7,200
$14,400
$9,600
Expenses for Dependents 同行者費用 $1,500 x #
$3,000 x #
$4,500 x #
$6,000 x #
Total
$ ＄12,300
$
$
$
Total amount calculation sheet 総額早見表
Number of family member(s)
X Student Only
 Student and Spouse
 Student, Spouse and one child
 Student, Spouse and two children
 Student, Spouse and three children
Financial Support Form (11/08)
 3 months
X 6 months
$6,300
$7,800
$9,300
$10,800
$12,300
$12,300
$15,300
$18,300
$21,300
$24,300
Page 2
 9 months
$18,200
$22,700
$27,200
$31,700
$36,200
 12 months
$24,000
$30,000
$36,000
$42,000
$48,000
www.nybi.org

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