I-912 Form TOC

TABLE OF CHANGES – FORM

Form I-912, Request for Fee Waiver

30 day public comment period

OMB Number: 1615-0116

Revised 10/09/2012

Reason for Revision: Form is expiring in October 2012. Some modifications to language have been made to clarify sections.

Current Section and Page Number	Current Text	Location and Proposed Text
Page 1, Section 1, Information About You	Information About You	Page 1, Section 1 Information About You (Provide information about yourself. If you are applying for a minor child, provide information about the minor child).
Section 1, Information About You, Line 3	U.S. Social Security Number (SSN) (9 numbers only)	Page 1, Section 1, Information About You Deleted Social Security Number Field; renumbered items that follow;
Section 2, Additional Information if Dependent(s) are Included in This Request,	Additional Information if Dependent(s) are Included in This Request	Page 1, Section 2. Additional Information for Dependent(s)
Section 2, Additional Information if Dependent(s) are Included in This Request, Line 7, Column 3	SSN (If applicable)	Page 1, Line 6 Deleted 3rd column named “SSN”; inserted new column entitled: “Is Individual Included in Fee Waiver Request?” Y es No
Page 2, Section 5. Household Income (Provide evidence of monthly income or other support.), Line 10	Line 10. How many dependents (for tax purposes) live with you?	Page 2, Section 5. Household Income (Provide evidence of monthly income or other support.) Line 9. Other than you, how many others in your household depend on the stated income? Line 11. Enter other money received each month that is not included in Line 14. This could include spousal support, child support, unemployment compensation, etc.
Page 3, Section 6. Financial Hardship, Line 13	Describe your particular situation. Be sure to include how this situation has caused you to incur costs (and what the costs were) or loss of income that you have experienced (and what that loss was). (If you need more space, attach a separate sheet of paper.)	Page 3, Section 6. Financial Hardship, Line 12 Describe your particular situation. Be sure to include how this situation has caused you to incur costs (and what the costs were) or loss of income that you have experienced (and what that loss was). Complete this section in English; otherwise, provide an accompanying English translation. (If you need more space, attach a separate sheet of paper.)
Page 4, Section 6, Financial Hardship, Line 17		Page 4, Section 6., Financial Hardship Line 16 New text: Under 2d “Type of Cost” column: “Other Expenses” added above TOTAL Monthly Costs.
Section 7, Your Signature and Authorization, Line 18	Your Signature Additional Signature Date	Page 4-5, Section 7. Your Signature and Authorization Added a field beneath each signature line requiring each applicant signing the fee waiver to type/print their name. Your Signature_____________ Printed Name______________ Date (mm/dd/yyyy)___________

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