Request for Dependent DS-2019

Please complete the following form and attach required documentation for all dependents requested.
-Copy of dependent’s biographical page of passport
-Financial Guarantee
Spouse: $850 per month ($10,200/year), Child: $450 per month ($5,400/year)

J-1 Exchange Visitor’s Name J-1 Exchange Visitor’s Name First Last
J-1 Exchange Visitor’s Email
How many dependent DS-2019 do you want to request?
1st Dependent Information:
Name Name First Last
Relationship
Date of Birth Date of Birth / MM / DD YYYY
City of Birth
Country of Birth
Country of Citizenship
Email
2nd Dependent Information:
Name Name First Last
Relationship
Date of Birth Date of Birth / MM / DD YYYY
City of Birth
Country of Birth
Country of Citizenship
Email
3rd Dependent Information:
Name Name First Last
Relationship
Date of Birth Date of Birth / MM / DD YYYY
City of Birth
Country of Birth
Country of Citizenship
Email
4th Dependent Information:
Name Name First Last
Relationship
Date of Birth Date of Birth / MM / DD YYYY
City of Birth
Country of Birth
Country of Citizenship
Email
*Dependents who are under the age of 18 are not required to provide an email address.
Dependents' biographical page of passport

Attach Files

You can upload more than one file.
Financial Guarantee(s)

Attach Files

You can upload more than one file.
I understand that:
1.I am responsible for checking in with the ISS Office within 10 days of the first arrival and prior to the finaldeparture of all J-2 dependents.
2.All J-2 dependents must secure and maintain health insurance meeting the minimum US Department ofState requirements for the duration of their stay in the US.
3.I am responsible for providing the ISS Office with a current address in the event that any or all of my dependents are living separately from me.
“I hereby certify the above information is true and accurate.”

“I hereby certify the above information is true and accurate.” Agree
Signature of Student

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
For ISS Use Only:
Date Received
Received by
Date DS-2019 Issued

Request for Dependent DS-2019

Request for Dependent DS-2019

1st Dependent Information:

2nd Dependent Information:

3rd Dependent Information:

4th Dependent Information:

*Dependents who are under the age of 18 are not required to provide an email address.

For ISS Use Only: