Pta

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
[email protected]
Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms. This
specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this PTA
to assess internal, component-specific forms as well.
Form Number:

Form I-912

Form Title:
Component:

Request for Fee Waiver
U.S. Citizenship and
Immigration Services
(USCIS)

Office:

Office of Intake and
Document Production
(OIDP)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title: Form I-912, Request for Fee Waiver
OMB Control
1615-0116
OMB Expiration
April 30, 2018
Number:
Date:
Collection status: Extension
Date of last PTA (if February 20, 2015
applicable):

Name:
Office:
Phone:

PROJECT OR PROGRAM MANAGER
Ernest DeStefano
OIDP
Title:
Chief
2022334237
Email:
[email protected]

Name:
Office:
Phone:

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Sheri Sheehan
OIDP
Title:
Division Chief
8026520410
Email:
[email protected]

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

SPECIFIC IC/Forms PTA QUESTIONS
1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
USCIS is submitting this PTA to document the extension of the Form I-912. The form and
instructions have not been revised. USCIS did not revise the USCIS Fee Waiver Guidelines
Policy Memorandum. Individuals will continue to request a fee waiver by filing a paper
waiver with the USCIS Lockbox. USCIS is updating this PTA to account for USCIS Electric
Information System (USCIS ELIS) maintaining a scanned copy of the Form I-912.
I-912, Request for Fee Waiver
The Office of Intake and Document Production (OIDP) leads the processes that support the
beginning and end of most immigration transactions. Support for the beginning of the
immigration process includes managing USCIS’ forms design, printing and distribution
processes, as well as those associated with application intake and fee collection.
USCIS is funded largely by those fees. Individuals may apply for and be granted a fee
waiver for certain immigration benefits and services based on an inability to pay
[authority is provided in Title 8 CFR 103.7(c) and INA section 286(m)]. The final rule “U.S.
Citizenship and Immigration Services Fee Schedule,” effective December 23, 2016,
established a new fee schedule for immigration-benefit requests and amended the
regulations governing fee-waiver eligibility. USCIS developed Form I-912, Request for Fee
Waiver, in an effort to facilitate the fee waiver adjudication process and provide a standard
means for submitting a fee waiver request.
In general, fee waiver requests are reviewed by considering, in a step approach, whether
the applicant is receiving a means-tested benefit, whether the applicant’s household
income level renders him or her unable to pay, or whether recent financial hardship
otherwise renders him or her unable to pay.
Form I-912 must be filed with an application or petition requesting an immigration
benefit. The completed USCIS application(s) or petition(s), Form I-912, and all supporting
documentation must be mailed to the USCIS office according to the “Where to File”
directions in the application or petition form instructions to which the Form I-912 relates.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

The information requested on Form I-912 and the associated evidence is collected under
the Immigration and Nationality Act, section 101, et seq. The primary purpose for
providing the requested information is to determine whether the individual has
demonstrated an inability to pay the related application/petition fee(s) and ultimately to
approve or deny the fee waiver request. The information is provided voluntarily by the
applicant/petitioner. However, failure to provide the requested information and any
requested evidence may delay a final decision or result in denying the fee waiver request
and rejecting the application or petition based on non-payment of the fee.
Relevant IT Systems:
Upon receipt from the Lockbox, the image of the Form I-912 is scanned as supporting
documentation to the underlying application/petition and stored in either the Enterprise
Document Management System (EDMS) or USCIS ELIS, USCISs repositories for digitized
versions of paper Alien-Files (A-Files) and Receipt Files. Additionally, depending on the
form and support case tracking system, the acceptance or rejection of the fee waiver
request is captured in the history action codes of Computer Linked Application
Information Management System (CLAIMS 3) or CLAIMS 4. If the form is processed in
USCIS Electric Information System (USCIS ELIS) Form I-912 images will be maintained in
USCIS ELIS as the official record and a history action code is also captured in USCIS ELIS.
b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
USCIS is funded largely by application and petition fees. Recognizing that some
applicants cannot pay the filing fees, USCIS established a fee waiver process for certain
forms and benefit types. We will approve a fee waiver only if you clearly demonstrate
that you are unable to pay the filing fee
s. USCIS carefully considers the merits of each fee waiver request before making a
decision. See regulations: 8 CFR 103.7(c)(3)).

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII1)?
b. From which type(s) of
individuals does this form

☒ Yes
☐ No
☒ Members of the public

1

Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including
any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident,
visitor to the U.S., or employee or contractor to the Department.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

collect information?
(Check all that apply.)

☒ U.S. citizens or lawful permanent
residents
☒ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

c. Who will complete and
submit this form? (Check
all that apply.)

☒ The record subject of the form (e.g., the
individual applicant).
☒ Legal Representative (preparer, attorney,
etc.).
☐ Business entity.
If a business entity, is the only
information collected business contact
information?
☐ Yes
☐ No
☐ Law enforcement.
☐ DHS employee or contractor.
☒ Other individual/entity/organization that is
NOT the record subject. Please describe.
Interpreter and preparer.

d. How do individuals
complete the form? Check
all that apply.

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
The primary purpose for providing the requested information in Form I-912 is to
determine whether the individual has demonstrated an inability to pay the related
application/petition fee(s) and ultimately to approve or deny the fee waiver request.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Specifically, the applicant/petitioner provides:
 Basis for the request
 Full Name
 Alien Registration Number (A-Number)
 Online Account Number
 Social Security number (SSN)
 Date of Birth
 Marital Status
 Immigration Status
 Classification
 Employment Status
 Application/Petition for which the request is being submitted with
 Information regarding award of a Means-Tested Benefit
o name of person receiving the benefit
o name of agency awarding the benefit, and
o date benefit was awarded
 Household Income (including evidence of income or other support)
 Explanation of Financial Hardship Employment Status
 Assets and their Value
 Average Costs (including evidence of monthly costs and payments)
 Signature
Information about the dependents includes:
 Full name
 A-Number
 Date of Birth
 Relationship to the applicant/petitioner
Information about the Preparer includes:
 Full Name
 Business or Organization
 Mailing Address
 Telephone Number
 Fax Number
 Email Address
 Signature
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Information about the Interpreter includes:
 Full Name
 Business or Organization
 Mailing Address
 Telephone Number
 Email Address
 Signature
Data elements 2 through 6 help ensure the I-912 can be matched to the application or
petition. The rest of the data elements listed above are used for adjudication of the fee
waiver request.
f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.
☒ Social Security number
☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☒ Alien Number (A-Number)
☐ Social Media Handle/ID
☐ Tax Identification Number
☐ Known Traveler Number
☐ Visa Number
☐ Trusted Traveler Number (Global
☐ Passport Number
Entry, Pre-Check, etc.)
☐ Bank Account, Credit Card, or other
☐ Driver’s License Number
financial account number
☐ Biometrics
☒ Other. Please list: Online Account
Number
g. List the specific authority to collect SSN or these other SPII elements.
Individuals may apply for and be granted a fee waiver for certain immigration benefits
and services based on an inability to pay [authority is provided in Title 8 CFR 103.7(c)
and INA section 286(m)]. The final rule “U.S. Citizenship and Immigration Services Fee
Schedule,” effective December 23, 2016, established a new fee schedule for immigrationbenefit requests and amended the regulations governing fee-waiver eligibility.
The Social Security Number (SSN) is included to provide the applicant with clearer
options for providing their information and assisting USCIS in identifying the applicant,
matching up documentation and reducing or deterring cases of fraud.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
USCIS uses the SSN in identifying the applicant, matching up documentation and
reducing or deterring cases of fraud. For example if an Applicant shares the same name
with a member of their family also identified on the form, without the inclusion of the
SSN, a USCIS analyst may not be able to match the Means-Tested Benefits (MTB), tax, and
income supporting documents to the applicant and the application could be may be
denied. It can also be utilized to ensure the benefit is being issued to the correct
individual.
i. Are individuals
☒ Yes. Please describe how notice is provided.
provided notice at the
Applicants or representative provide the
time of collection by
information in the form I-912 at the time of filing.
DHS (Does the records
A Privacy Notice is included on the form
subject have notice of
instructions.
the collection or is
☐ No.
form filled out by
third party)?

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
The Form I-912 will be retained in the
completed IC/forms?
applicants’/petitioners’ A-File.
☐ Electronic. Please describe the IT system that will
store the data from the form.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
The image of the Form I-912 is scanned as
supporting documentation into the Enterprise
Document Management System (EDMS), part of the
Integrated Digitization Document Management
Program (IDDMP).
The image of the Form I-912 is also scanned as
supporting documentation into the Electronic
Immigration System (USCIS ELIS).
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

b. If electronic, how
does DHS input the
responses into the IT
system?

☐ Manually (data elements manually entered). Please
describe.
Click here to enter text.
☐ Automatically. Please describe.
Click here to enter text.

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?

☒ By a unique identifier.2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
 Full Name
 Alien Registration Number (A-Number)
 USCIS Online Account Number
 SSN
 Date of Birth
☒ By a non-personal identifier. Please describe.
Receipt Number
Transaction Number
A-Files, including USCIS ELIS[N1-566-08-11] –
permanent records
EDMS: [N1-566-08-17] – permanent records

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
USCIS follows the records retention schedule for filing
that records are
and destruction of records.
disposed of or deleted
in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
2

Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.
☒ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Jenny Hoots

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:

June 15, 2017

Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component Privacy
Act Statements.)

July 24, 2017
☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The USCIS Privacy Office recommendation is to designate Form I-912 as a privacy sensitive
form with coverage under the following:
PIA







DHS/USCIS/PIA-003 - Integrated Digitization Document Management Program
(IDDMP), which covers the digitization of paper-based case files (A-Files and
Receipt Files) and storing them in the EDMS.
DHS/USCIS/PIA-015 Computer Linked Application Information Management
System (CLAIMS 4), which covers the action history code in CLAIMS 4.
DHS/USCIS/PIA-016 - Benefits Processing of Applicants other than Petitions
for Naturalization, Refugee Status, and Asylum (CLAIMS 3), which covers the
action history code in CLAIMS 3.
DHS-USCIS-PIA-056 USCIS ELIS, which covers the digitization of paper-based case
files (A-Files and Receipt Files) and storing them in the USCIS ELIS as well as the
history code.

SORN
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy



DHS/USCIS-001 - Alien File, Index, and National File Tracking System of
Records, which covers the collection, use, and maintenance of A-Files.



DHS-USCIS-007 - Benefits Information System, which covers the collection, use,
and storage of benefit waivers.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Kameron Cox

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1147221
July 28, 2017
July 28, 2018

DESIGNATION
Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

Determination:

☐ PTA sufficient at this time.
☐ Privacy compliance documentation determination in
progress.
☐ New information sharing arrangement is required.
☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

DHS IC/Forms Review:

DHS PRIV has not received this ICR/Form.

Date IC/Form Approved
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
Choose an item.
Statement:
A privacy notice is required
PTA:
Choose an item.
Current system PTA is adequate
PIA:
PIA Appendix update required
If covered by existing PIA, please list:
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

DHS/USCIS/PIA-003(b) Integrated Digitization Document Management
Program (IDDMP)
DHS/USCIS/PIA-015 Computer Linked Application Information
Management System (CLAIMS 4)
DHS/USCIS/PIA-016(a) Computer Linked Application Information
Management System (CLAIMS 3) and Associated Systems
DHS/USCIS/PIA-056 USCIS ELIS
If a PIA update is required, please list:
SORN:
System covered by existing SORN
If covered by existing SORN, please list:
DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking
System of Records, November 21, 2013, 78 FR 69864
DHS/USCIS-007 Benefits Information System, October 19, 2016, 81 FR
72069
If a SORN update is required, please list:
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
USCIS is submitting this PTA to document the extension of the Form I-912. The form and
instructions have not been revised. USCIS did not revise the USCIS Fee Waiver Guidelines Policy
Memorandum. Individuals will continue to request a fee waiver by filing a paper waiver with the
USCIS Lockbox. USCIS is updating this PTA to account for USCIS Electric Information System
(USCIS ELIS) maintaining a scanned copy of the Form I-912.
The DHS Privacy Office (PRIV) finds that the I-912 is a privacy sensitive form because it
collects PII from members of the public. PRIV agrees with USCIS’s recommendation that a PIA
is required because the I-912 form collects PII from members of the public. PRIV concludes
there is adequate coverage from existing PIAs. DHS/USCIS/PIA-015 Computer Linked
Application Information Management System (CLAIMS 4) and DHS/USCIS/PIA 016 Benefits
Processing of Applicants other than Petitions for Naturalization, Refugee Status, and Asylum
(CLAIMS 3) properly assesses the privacy risks for the collection and use of the information
contained on form I-912. DHS/USCIS/PIA-003 Integrated Digitization Document Management
Program (IDDMP) covers the digitization of form I-912 and its storage in EDMS systems with
its history code. PRIV finds, however, that DHS/USCIS/PIA-056 USCIS ELIS requires an
updated Appendix A to include the form I-912 to provide coverage for storage on the system.
PRIV finds that a SORN is required because the information collected by form I-912 is retrieved
by unique identifier. This collection is covered by DHS-USCIS-007 Benefits Information
System, which covers the collection, use, and storage of financial information for the purposes of

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

processing benefit requests. DHS/USCIS-001 Alien File, Index, and National File Tracking
System of Records, covers the collection, use, and maintenance of form I-912 within A-Files.
PRIV finds that a Privacy Notice is required to inform the individual about the authority to
collect the information requested, purposes for collecting it, routine uses, and consequences of
providing or declining to provide the information to USCIS.
This PTA will expire in one year. Two additional years coverage will be provided from the date
of adjudication following the publishing of an update to USCIS ELIS Appendix A

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