C onfidential s tatement for

/ / 
Printed Name of Bank Official and Bank Official’s Title:
Bank address:
Bank official telephone number:
*Place 
bank 
seal 
here 
or 
attach 
a 
bank 
statement.
0322
I certify that I have read the information provided by the applicant on this form, that it is a true and accurate statement, and that the funds are available and will be 
provided as indicated. Electronic signatures will not be accepted.
Parent’s or sponsor’s signature
Relationship to applicant 
Date signed /
/
(MM/DD/YYYY)
SECTION D SOURCES OF SUPPORT FOR FINANCING STUDY AT BOSTON UNIVERSITY
Student’s family name(s): 
(
p r i n t e d
a s
i t
a p p e a r s
o n
p a s s p o r t
)
Student’s given name(s):
(
p r i n t e d
a s
i t
a p p e a r s
o n
p a s s p o r t
)
BU ID number: 
Date of Birth: 
/ /
Foreign address outside U.S. (required for production of Form I-20) 
Number and street 
City
Country
Province or state 
Zip/postal code
Month Day Year
I certify that the statements given by me in this form are complete and accurate. Furthermore, I agree to assume all financial responsibilities should my source(s) of 
funding, as specified above, be interrupted or stopped. Electronic signatures will not be accepted.
Student’s signature
Date signed
/
/
(MM/DD/YYYY)
Name of parent(s)/sponsor(s):
(
p l e a s e
p r i n t
) 
Amount of assured support (in U.S. dollars): $
Name of bank: 
(
p l e a s e
p r i n t
)
A bank official’s signature is required on the certification if the student is 
partially or totally supported by personal or family savings, or private funds. If 
funds are from more than one source or bank, use an additional form; only one 
source or bank account can be documented on each form.
Month Day Year