UCLA - Dashew Center for nternational Students and Scholars

F-1 I-20 REQUEST

Student's Name: ___________________________________________________________________
(as indicated on passport) Last Name First Name Middle Name

UCLA D #: ___________________________ Date of Birth: ________________________________
Month Day Year
Country of Birth: _______________________ Citizenship: __________________________________
SEVS D #: N__________________ Degree Objective: Bachelor's Master's Doctorate
Major: ______________________________ Expected Degree Completion Term: _______________
(as indicated on your I-20 form)
E-Mail: ______________________________ Telephone #: _________________________________

Local U.S. Address:_________________________________________________________________

Foreign Address: __________________________________________________________________


REASON FOR REQUESTING NEW I-20

Lost/Damaged Original Change of Funding (must submit new proof of funding)

Change of Education Level/New Degree Objective
(must submit new proof of funding and confirmation to new degree by the Graduate Division)

Name Change/Correction New Major: ___________________________________
(must submit copy of passport photopage)
Return From Leave of Absence/Readmissions: _______________________________________
(must submit new proof of funding and copy of passport photopage) (expected return quarter)

Other (please explain): ___________________________________________________________

New F-2 Dependent -20 (Must submit copy of marriage certificate, dependents passport photopage,
and proof of funding: $4,500 for spouse and $2,000 per child). Please complete below:

Dependents Name (Last, First) Date of birth
(MM/DD/YYYY)
Country of
Birth
Citizenship Relationship










FOR OFFICE
USE ONLY

INIT: ___________ DATE: _____________________



106 Bradley International Hall 417 Charles Young Dri ve West, Los Angeles, CA 90095-1379 Phone: 310-825-1681 Fax: 310-206-1612
Funding Restriction Holds Current Enrollment Past Enrollment Current I-20 Update I-20