I-912 Request for Fee Waiver

Request for Fee Waiver

USCIS
Form I-912

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Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0116
Expires 10/31/2012

►Before you fill out this form, please read the instructions.

FOR USCIS USE ONLY

Section 1. Information About You (Provide information about yourself. If you
are applying for a minor child, provide information about the minor child.)

Application Receipted At
(check only one box):

USCIS Field Office
Line 1. a. Family Name (Last Name)

Fee Waiver Approved

Line 1. b. Given Name (First Name)

Date:______________

Line 1. c. Middle Initial
Line 2.

Alien Registration Number

Line 3.

Date of Birth

Line 4.

Marital Status

Line 5.

For

Fee Waiver Denied

► A-

Date:______________

(mm/dd/yyyy) ►

USCIS Service Center

Never Married

Divorced

Marriage Annulled

Fee Waiver Approved

Married

Widow(er)

Legally Separated

Date:______________
Fee Waiver Denied

Applications and Petitions (Enter the form number(s) of the application(s) and/or
petition(s) for which you are requesting a fee waiver.

Date:______________

Biometrics services fees, where applicable, will be included in the fee waiver request.

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Section 2. Additional Information for Dependent(s)
Line 6.

Complete the Table below if applicable. (If you need more space, attach a separate sheet of paper.)
Name (First, MI, Last)

Form I-912 10/09/12 Y

A-Number
(If applicable)

Is Individual
Included in Fee
Waiver Request?

A-

Yes

No

A-

Yes

No

A-

Yes

No

A-

Yes

No

A-

Yes

No

A-

Yes

No

A-

Yes

No

Date of Birth

Relationship to You

(mm/dd/yyyy)

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Section 3. Basis for Your Request (Check any that apply. For additional information, see the form
instructions.)
Line 7. a.

I am or a relevant member of my household is currently receiving a means-tested benefit. (Complete Sections 4 and 7.)

Line 7. b.

My household income is at or below 150% of the Federal Poverty Guidelines. (Complete Sections 5 and 7.)

Line 7. c.

I have a financial hardship. (Complete Sections 5, 6 and 7.)

Section 4. Means-Tested Benefit
Line 8.

Complete the Table Below (If you need more space, attach a separate sheet of paper.)
Name of Person
Receiving the Benefit

For
Name of Agency
Awarding Benefit

Date Benefit
Was Awarded

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Is This Benefit Being
Received Now?
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

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?

►
(round to the nearest dollar)

Line 10.

Average monthly wage income from household members

►

Line 11.

Enter other money received each month that is not included in Line 14.
This could include spousal support, child support, unemployment, etc.)

►

TOTAL (USCIS will compare this amount to Federal Poverty Guidelines)

►

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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.)

For
If you are currently unemployed, you must complete Lines 13 and 14.
(mm/dd/yyyy) ►

Line 13.

Date that you became unemployed

Line 14.

Amount of unemployment compensation (monthly) that you are receiving (enter dollars)

Line 15.

List your assets and the value of your assets. (If you need more space, attach a separate sheet of paper.)

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Value (enter dollars)

Type of Asset

TOTAL Value of Assets

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Section 6. Financial Hardship (Cont'd)
Line 16.

List your average monthly costs, and provide evidence of monthly payments where possible. (If you need more space,
attach a separate sheet of paper.)
Type of Cost

Value (Enter Dollars)

Type of Cost

Rent

Loan Payment

Mortgage

Commuting Costs

Food

Medical

Utilities

Value (Enter Dollars)

For
School

Child/Elder Care
Insurance

Other Expenses
TOTAL Monthly Costs

Section 7. Your Signature and Authorization
Do not sign your Form I-912 until it is complete and you are ready to file.
I take full responsibility for the accuracy of all the information provided, including all supporting documentation. I authorize the
release of any information, including the release of my Federal tax returns, that USCIS needs to determine my eligibility.

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Each person applying for a fee waiver request must sign Form I-912. This includes individuals identified in Sections 1 and 2 if
14 years of age or older. (If you need more space, attach a separate sheet of paper.)
Line 17.

Your Signature

Date (mm/dd/yyyy) ►

Printed Name
Line 17.1. Additional Signature

Date (mm/dd/yyyy) ►

Printed Name

Line 17.2. Additional Signature

Date (mm/dd/yyyy) ►

Printed Name

Line 17.3. Additional Signature

Date (mm/dd/yyyy) ►

Printed Name

Line 17.4. Additional Signature

Date (mm/dd/yyyy) ►

Printed Name

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Section 7. Your Signature and Authorization (continued)

Date (mm/dd/yyyy) ►

Line 17.5. Additional Signature
Printed Name

Date (mm/dd/yyyy) ►

Line 17.6. Additional Signature
Printed Name

Line 17.7. Additional Signature
Printed Name

For

Date (mm/dd/yyyy) ►

Production

Form I-912 10/09/12 Y

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