FINANCIAL DATA QUESTIONNAIRE

STUDENT VISA APPLICATION

AMERICAN CONSULATE GENERAL
CHENNAI

I, (Name of CA), Fellow Member of the Institute of Chartered Accountants of

India, do hereby certify that I have reviewed the financial condition of Mr. ...........
(Father) and Mrs. ....... (Mother), parents of XYZ with a view to establishing their
ability to pay the educational cost of their daughter XYZ for the M.E.M (Master of
Engineering Management) program of study at the ....... University, U.S.A, which has
been estimated to be US $ ............ per year as per the I-20 issued by the University.

Sl SOURCES OF FUNDS US $ INDIAN REFERENC

Rs. E
(Annexures)
1 Scholarship Nil Nil Nil
2 Savings in India
(a) Movable Assets I
(b) Immovable Assets II
3 Personal/ Family savings from Nil Nil --
abroad
4 Current Income from India III
5 Current Income from abroad Nil Nil --
6 Loans Nil Nil --
7 Other Sources Nil Nil --
TOTAL --

Notes:
[1] Exchange Rate: 1 US $ = Rs.
[2] Amounts are rounded off to the nearest Rupee or Dollar as the case may be
[3] The applicant is sponsored by his parents
 :: 2 ::

MOVABLE ASSETS
ANNEXURE – I

Sl NATURE OF ASSET US $ Indian

. Rupees Rs.

1. Balance in Savings Bank Account No. of…..

(Mother/Father of the applicant) with ....... Bank of
Travancore, Sasthamangalam Branch,
Thiruvananthapuram City, Kerala State,(as per
Bank Certificate).

2. Fixed Deposits in the names of ….(Parents of the

applicant) with State Bank of Travancore,
Thiruvananthapuram City (as per FD receipts)

TOTAL
 :: 3 ::

IMMOVABLE ASSETS
ANNEXURE – III

Sl NATURE OF PROPERTY US $ Indian

. Rupees Rs.
1. Urban site belonging to … (Mother of the applicant)
with residential buildings bearing T.C.5/2430-1,
measuring 3.75 ares (9.26 cents) situated at RE Sy
No.24, Block No.19,T.P No. 20884 of Peroorkada
Village, Thiruvananthapuram Taluk,
Thiruvananthapuram District (as per Building and
Property Valuation certificate given by Chartered
Engineer and Approved Valuator ,
Thiruvananthapuram City).

TOTAL
 :: 4 ::

CURRENT INCOME FROM INDIA

ANNEXURE – IV

Sl US $ Indian
. Rupees Rs.
1. Net Annual Salary income of ….. (Father of
applicant) as (Job title) (as per Form-16 and Salary
Certificate)

2. Net Annual Salary income of ….. (Mother of

applicant) as Single Window Operator (as per
Form-16 and Salary Certificate)

.
TOTAL

I hereby declare that the above certificate has been given by me on the basis of
the original documents, affidavits of the student’s parents, relevant certificates and
property documents. After reviewing the financial condition of Mr ............., I find
them financially sound to meet the education and living expenses of their daughter
XYZ for her M.E.M (Master of Engineering Management) program at the Duke
University.

(Chartered Accountant)
(Round Seal)