Scholar Status Report Form 1204

internationaloffice.berkeley.edu

J Scholar Status Report Form The purpose of this form is to notify Berkeley International Office of any of the events listed below that may affect the scholar’s SEVIS/immigration status during his or her stay in the U.S. This is a fillable form available on our web site at http://internationaloffice.berkeley.edu/ucb_departments/J-1 . Save the completed form to your computer and then submit it via email attachment to [email protected]. You may fax this form to BIO at 643- 7289, although email is preferable.

General Information Complete this section for all reports. Then, complete the section(s) below that apply to your case. Family Name (as appears in passport) Male First and Other Names (as appears in passport) Female Date of Birth (mm/dd/year) SEVIS ID# (found above bar code on DS-2019) Home Phone Campus Phone Email

Department Name Phone

Department Administrator’s Name Email

Arrival Please inform the scholar to attend the required Scholar Information Meetings (SIMs). Submit this form within 9 days of the start date on the DS-2019 with a copy of the passport admission stamp indicating “J-1 D/S”, or a copy of the paper or electronic I-94 record (https://i94.cbp.dhs.gov/I94/request.html). Scholar’s Actual Arrival Date in the U.S Attach a copy the passport admission stamp indicating “J-1 D/S”, or a copy of the paper or electronic I-94 record. Street Address Apt. # (if any) Room # (if any)

City State Zip Code

Deferral of Arrival If the scholar is unable to enter within 9 days of the start date on the DS-2019, complete this section. If the scholar requires a second deferral, please email [email protected] to discuss the possible need for a new document. Yes Has scholar already applied for a J-1 visa stamp using the current DS-2019? New Arrival Date in the U.S. (mm/dd/year) No

Reason for Delay:

Change of Address Submit this form within 10 days of a scholar’s change in residential address.

New Street Address Apt. # (if any) Room # (if any)

City State Zip Code

Effective Date of Change (mm/dd/year)

Early Program Completion Submit this form before the new program completion date (the earlier, the better!)

Departure from U.S. more than 15 days before the end date on Does the scholar plan to return to the U.S. within 24 months? No Yes the DS-2019, and does not intend to return to UC Berkeley or If yes, please indicate anticipated date of return below. another institution in the U.S. -Date of departure (mm/dd/year) - Date or return (mm/dd/year)

Transfer to another institution in the U.S Contact Person at New Institution - Date of transfer (mm/dd/yy) Contact Phone - Name of New Institution Contact Email

Terminated by the Department Effective Date of Termination - Contact Berkeley International Office in this case

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