DS-2019 Extension Request Form
Print this form, fill it out and deliver it to the OFSS office at the address below. It will take 7 days to process.
| Today's Date: | |
| Last Name: | |
| First Name: | |
| Date of Birth: | |
| Local Address: | |
| E-mail Address: | |
| Daytime telephone: | |
| Department: | |
| Funding ** (Personal, departmental, government, etc.): |
** If you are funded by your department or any governmental institution, you must provide a letter stating the amount of funding you will receive for the duration of the extension. As this amount appears on the DS-2019 form, the DS-2019 will not be prepared until the Office of Foreign Students & Scholars (OFSS) has received the information. If you are not funded, a personal bank statement is required. You need to show $10,000 for yourself and $3000 for each dependent.
If you have family members here with you on J-2 visas, please list below:
Dependent 1| Last Name: | |
| First Name: | |
| Date of Birth (mm/dd/yyyy): | |
| City and Country of Birth: | |
| Relationship: |
Dependent 2
| Last Name: | |
| First Name: | |
| Date of Birth (mm/dd/yyyy): | |
| City and Country of Birth: | |
| Relationship: |
Dependent 3
| Last Name: | |
| First Name: | |
| Date of Birth (mm/dd/yyyy): | |
| City Country of Birth: | |
| Relationship: |
I certify that I have medical insurance coverage for myself and my dependent/s.
| Signature: | |
| Date: |