Department of Homeland Security
U.S. Immigration and Customs Enforcement

I-20, Certificate of Eligibility for Nonimmigrant Student Status
OMB NO. 1653-0038

SEVIS ID: N0004720633
SURNAME/PRIMARY NAMESample

GIVEN NAME
Student

PREFERRED NAME
Student Sample, II

PASSPORT NAMECOUNTRY OF BIRTHLAOSCOUNTRY OF CITIZENSHIPLAOSDATE OF BIRTH
04 MAY 1995

ADMISSION NUMBER

FORM ISSUE REASONCONTINUED ATTENDANCELEGACY NAMEClass of Admission

F-1
ACADEMIC ANDLANGUAGESCHOOL INFORMATIONSCHOOL NAMESEVP School for Advanced SEVIS Studies
SEVP School for Advanced SEVIS Studies

SCHOOL ADDRESS
9002 Nancy Lane, Ft. Washington, MD 20744

SCHOOL OFFICIAL TO CONTACT UPON ARRIVAL
Helene RobertsonPDSO

SCHOOL CODE AND APPROVAL DATEBAL214F44444000
03 APRIL 2015

PROGRAM OF STUDYEDUCATION LEVELBACHELOR'S

MAJOR 1
History and Philosophy of Scienceand Technology 54.0104

MAJOR 2
None 00.0000

PROGRAM ENGLISH PROFICIENCYRequired

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

FINANCIALSESTIMATED AVERAGE COSTS FOR: 9 MONTHS
Tuition and Fees
Living Expenses
Expenses of Dependents (0)Other$$$$

15,0004,00000

STUDENT'S FUNDING FOR: 9 MONTHS
Personal Funds
Funds From This School
Funds From Another Source
On-Campus Employment

$
$
$
$

19,000TOTAL$

19,000TOTAL$

19,000

REMARKSSCHOOL ATTESTATIONI 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 UnitedStates 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 adesignated school official of the above named school and am authorized to issue this form.
XDATE ISSUED
PLACE ISSUED
SIGNATURE OF: Helene Robertson, PDSO
04 May 2016
Ft. Washington,MDSTUDENT ATTESTATION
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 thepurpose 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.
X
SIGNATURE OF: Student Sample

DATEX

NAME OF PARENT OR GUARDIANICE Form I-20 A-B (3/31/2018)

SIGNATURE

ADDRESS (city/state or province/country)

DATE

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Department of Homeland Security
U.S. Immigration and Customs Enforcement

I-20, Certificate of Eligibility for Nonimmigrant Student Status

SEVIS ID: N0004720633 (F-1)

NAME: Student Sample

OMB NO. 1653-0038

EMPLOYMENT AUTHORIZATIONSTYPECPTFULL/PART-TIMEPART TIMESTATUSAPPROVEDSTART DATE
01 JULY 2016

END DATE
15 JULY 2016

EMPLOYER INFORMATIONTYPECPTAUTHORIZATION DATES
01 JULY 2016 - 15 JULY 2016

EMPLOYER NAMESEVP applied labs

START DATE
01 JULY 2016

END DATE
15 JULY 2016

CITY & STATEArlington, VA

CHANGE OF STATUS/CAP-GAP EXTENSIONAUTHORIZED REDUCED COURSE LOAD
CURRENT SESSION DATESCURRENT SESSION START DATE
01 JUNE 2016

CURRENT SESSION END DATE
30 JUNE 2016

TRAVEL ENDORSEMENT
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. Eachendorsement is valid for one year.
SCHOOL OFFICIAL

TITLE

SIGNATURE

DATE ISSUED

PLACE ISSUEDXXXXICE Form I-20 A-B (3/31/2018)

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Department of Homeland Security
U.S. Immigration and Customs Enforcement

I-20, Certificate of Eligibility for Nonimmigrant Student Status

INSTRUCTIONS TO STUDENTS

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 DSOof your new address within 10 days of the change of address. The DSO willupdate SEVIS with your new address.

STUDENT ATTESTATION. You should read everything on this pagecarefully. Be sure that you understand the terms and conditions concerning youradmission 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, orusing any false document in the submission of this form.
FORM I-20. The Form I-20 (this form) is the primary document to show thatyou have been admitted to school in the United States and that you areauthorized 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 theschool named on your Form I-20.

OMB NO. 1653-0038

REENTRY. F-1 students may leave the United States and return within aperiod of five months.To return, you must have: 1) a valid passport; 2) a valid F1 student visa (unless you are exempt from visa requirements); and 3) your FormI-20, page 2, properly endorsed for reentry by your DSO. If you have been out ofthe 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 orupon request. Your signature on the Form I-20 authorizes the named school torelease such information from your records.

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 topresent 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 theUnited States. You must also provide evidence of support for tuition and fees
and living expenses while you are in the United States.

PENALTY. To maintain your nonimmigrant student status, you must: 1)
remain a full-time student at your authorized school; 2) engage only inauthorized employment; and 3) keep your passport valid. Failure to comply withthese regulations will result in the loss of your student status and subject you todeportation.

ADMISSION. When you enter the United States, you must present thefollowing 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; and4) 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.

Failure to comply with 8 CFR 214.3(k) and 8 CFR 214.4 when issuing Forms I20 will subject you and your school to criminal prosecution. If you issue thisform improperly, provide false information, or fail to submit required reports,
DHS may withdraw its certification of your school for attendance bynonimmigrant students.

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 theschool named on your Form I-20 and your F-1 visa (unless you are exempt fromvisa requirements). If you decide to attend another school before you enter theUnited 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 lossof your student status and subject you to deportation.

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 UnitedStates as an F-1 nonimmigrant and plans to transfer to your school; or 3) is in theUnited 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 thatthe form is completed and issued in accordance with regulations.

INSTRUCTIONS TO SCHOOLSEMPLOYMENT. Unlawful employment in the United States is a reason forterminating 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 incurricular practical training (CPT) if you have written permission from yourDSO. You may apply to U.S. Citizenship and Immigration Services (USCIS) foroff-campus employment authorization in three circumstances: 1) employmentwith an international organization; 2) severe and unexpected economic hardship;and 3) optional practical training (OPT) related to your degree. You must havewritten authorization from USCIS before you begin work. Contact your DSO fordetails. Your spouse or child (F-2 classification) may not work in the UnitedStatesENDORSEMENT OF PAGE 2 FOR REENTRY. If there have been nosubstantive 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 therehave been substantive changes, the DSO should issue and sign a new Form I-20
that includes those changes.

PERIOD OF STAY. You may remain in the United States while taking a fullcourse 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 thefollowing dates: 1) the program end date on your Form I-20 plus 60 days; 2) theend date of your OPT plus 60 days; or 3) the termination of your program forany other reason. Contact your DSO for details.

AUTHORITY FOR COLLECTING INFORMATION. Authority forcollecting the information on this and related student forms is contained in 8U.S.C. 1101 and 1184. The Department of State and DHS use this information todetermine 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.

EXTENSION OF PROGRAM. If you cannot complete the education programby the program end date on page 1 of your Form I-20, you should contact yourDSO at least 15 days before the program end date to request an extension.

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 existingdata sources, gather and maintain the needed data, and complete and review thecollection 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 informationcollection unless a form displays a currently valid OMB Control number. Send
comments regarding this burden estimate or any other aspect of this collection ofinformation, including suggestions for reducing this burden, to: Office of theChief Information Officer/Forms Management Branch, U.S. Immigration andCustoms Enforcement. 801 I Street NW Stop 5800, Washington, DC 205365800. Do not send the form to this address.

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 theDSO 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. TheDSO at the new school must update your registration in SEVIS.

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

RECORDKEEPING. DHS may request information concerning the student'simmigration status for various reasons. DSOs should retain all evidence ofacademic ability and financial resources on which admission was based, until
SEVIS shows the student's record completed or terminated.

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