Jamestown CollegeDeclaration of Finances
 
All funds should be entered in U.S. dollars.
 
Personal Information________________________________________________________
 
Full Legal Name:   Email: ________________________________________
 
____________________________________________
Last Name		   _________________________________
First Name		   _______________________
Middle Name
 
Home Address:
 
_________________________________________________________________________________________________________
Complete Address
 
Address for Reply (if different from home address):
 
_________________________________________________________________________________________________________
Complete Address
 
Date of Birth: ____/____/_____ (mm/dd/yyyy)
 
Country of Birth: _____________________________   Country of Citizenship: _____________________________
 
Parents' Information:
 
___________________________________________________
Father's/Stepfather's Full Name		   ___________________________________________________
Occupation
 
___________________________________________________
Mother's/Stepmother's Full Name		   ___________________________________________________
Occupation
 
__________________________________________________
Father's/Stepfather's Employer		   __________________________________________________
Mother's/Stepmother's Employer
 
How many people, including yourself, depend on your parents for their living expense? _________________
 
Who will be responsible for paying the expenses of your college education? _________________________________
 
If this person is someone other than you or your parents, please explain the relationship:
 
______________________________________________________________________________________________________
 
Financial Information________________________________________________________
 
Does your government impose restrictions on the exchange and release of funds for study in the U.S.?  Yes    No
 
(Please describe the restrictions) ______________________________________________________________________________
 
_____________________________________________________________________________________________________________
 
How will you pay for your travel to the U.S.? ____________________________________________________________________
 
What is your total family income in U.S. dollars? Please include assets that will be used to support your education:
 
a. Father's Work $_______________ h. Real Estate Holdings $_______________
 
b. Mother's Work $_______________ i. Pension/Retirement $_______________
 
c. Your Work $_______________ j. Other (Siblings, $_______________
 
d. Your Spouse's Work $_______________ Sponsors, etc.) Identify: _______________
 
e. Family Business $_______________ _______________
 
f. Interest/Dividends $_______________ _______________
 
g. Savings $_______________ Total $_______________
 
 
Do you anticipate a significant increase or decrease in your family's income or expenses in the next two years?  Yes    No
 
(Please explain) _________________________________________________________________________________________
 
_________________________________________________________________________________________________________
 
 
If your sponsor is other than your family, please indicate the source of the sponsor's funds:
 
a. Savings $______________________________________________________________________
 
b. Salary/Wages $______________________________________________________________________
 
c. Family Business $______________________________________________________________________
 
d. Other (Describe) $______________________________________________________________________
 
 
Jamestown College Annual Costs 2010-2011
 
Tuition and Fees $16,360
 
Room and Board $5,536
 
Books, Personal, Insurance* $1,500
 
(*varies according to individual needs)  
 
TOTAL $23,396
 
Amount and source of funds for your education: Amount Source
 
1st year in U.S. $_________ ____________________________
 
2nd year in U.S. $_________ ____________________________
 
3rd year in U.S. $_________ ____________________________
 
4th year in U.S. $_________ ____________________________
 
Verification of Financial Support________________________________________________
 
Please list all sources of financial support for your college expenses. Do this for each year your will attend Jamestown College.
 
Savings: Indicate how much money will be available for each year from your savings. Have this section signed by a bank official.
 
1st year $___________ 2nd year $___________ 3rd year $___________ 4th year $___________
 
 
Name of Bank:________________________________________________________________________________
 
Address of Bank:______________________________________________________________________________
 
This is to certify that I have read the information above, that it is accurate, and that these funds are available.
 
Signature of Bank Official:_____________________________________________________________________________________
(Today's Date)
 
Sponsor: Indicate how much money will be available for each year from your sponsor. Have this section signed by that person.
 
1st year $___________ 2nd year $___________ 3rd year $___________ 4th year $___________
 
 
Name of Sponsor:________________________________________________________________________________
 
Address of Sponsor:______________________________________________________________________________
 
This is to certify that I have read the information above, that it is accurate, and that these funds are available.
 
Signature of Sponsor:_____________________________________________________________________________________
(Today's Date)
 
Other Funding Source: Indicate how much money will be available for each year from another funding source. Have this section signed by that person.
 
1st year $___________ 2nd year $___________ 3rd year $___________ 4th year $___________
 
 
Name of Funding Source:________________________________________________________________________________
 
Address of Funding Source:______________________________________________________________________________
 
This is to certify that I have read the information above, that it is accurate, and that these funds are available.
 
Signature of Person Responsible for Funding:______________________________________________________________
(Today's Date)
 
Make sure all funds are in U.S. dollars.
 
To be considered for admission to Jamestown College, the "Declaration of Finances" must be completed and submitted to Jamestown College in addition to the application for admission.
 
 
_______________________________________
Applicant Signature		   __________________________
Today's Date
 
Mail with application to:
Office of Admissions, Jamestown College
6081 College Lane
Jamestown, ND 58405
USA
 
Statement of Nondiscrimination
Jamestown College confirms its support of the principles and practices of nondiscrimination and equality of races and sexes in its employment and in all of its programs, activities, and opportunities available to students. Jamestown College also affirms a commitment to nondiscrimination and reasonable accommodation of those students who are disabled. It is the expressed intent of Jamestown College to be in conformity with all laws relating to higher education which are consistent with our commitment to the Christian ethic, including Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Students who believe they may have a qualifying disability should request a complete copy of policies and procedures available from the Office of Admissions, the Learning and Academic Advising Center, the Vice President for Student Affairs or the Vice President for Business Affairs.