Form I-942 Request for Reduced Fee

Request for Reduced Fee

USCIS
Form I-942

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

OMB No.1615-0133
Expires 11/30/2018

Request Receipted At (Select only one box)
For
USCIS
Use
Only

USCIS Field Office

USCIS Service Center

Reduced Fee Approved

Reduced Fee Denied

Reduced Fee Approved

Reduced Fee Denied

Date:______________

Date:______________

Date:______________

Date:______________

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► START HERE - Type or print in black ink.

Part 1. Information About You (Requestor)

Provide information about yourself. If you are the legal guardian filing on behalf of a person with a physical disability or
developmental or mental impairment, provide information about the person for whom you are filing this form.
1.

Full Name

Family Name (Last Name)

2.

Date of Birth (mm/dd/yyyy)

4.

Marital Status

Single, Never Married

Given Name (First Name)

3.

Middle Name

Alien Registration Number (A-Number)
► A-

Married

Divorced

Widowed

Marriage Annulled

Separated

Other (Explain)

Part 2. Information About Family Members Filing This Request With You
1.

In the table below, add the family members filing this request with you
Full Name

A-Number (if any)

Date of Birth

Relationship to You

AAAA-

Part 3. Household Income
Your Employment Status
1.

Employment Status
Employed (full-time, part-time,
seasonal, self-employed)

Form I-942 12/23/16 N

Unemployed or
Not Employed

Retired

Other (Explain)

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Part 3. Household Income (continued)
Information About Your Spouse
2.

If you are married or separated, does your spouse live in your household?

Yes

No

A. If you answered “No” to Item Number 2., does your spouse provide any financial support to your
household?

Yes

No

Yes

No

Your Household Size
3.

Are you the person providing the primary financial support for your household?

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If you answered “Yes” to Item Number 3., type or print your name on the line marked “self” in the table below. If you answered
“No” to Item Number 3., type or print your name on the line marked “self” in the table below and add the head of household's
name on the line below yours.

Household Size

Full
Name

Date of
Birth

Relationship
to You

Full-Time
Student

Married

Self

Does Person Earn
Income Counted Toward
Household Income?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Total Household Size (including self)

Your Annual Household Income

Provide information about your income and the income of all family members counted as part of your household. You must list all
amounts in U.S. dollars.
4.

Your Annual Income

5.

Annual Income of All Household Members

Provide the annual income of all family members counted as part of your household as listed above under Household Size in
Item Number 3. (Do not include the amount provided in Item Number 4.)
6.

Total Additional Income or Financial Support
Provide the total annual amount you receive in additional regular income or financial support from a source outside of your
household. (Do not include the amount provided in Item Number 4. or 5.) You must add all of the additional income and
financial support amounts that you regularly receive and put the total amount in the space provided. Type or print "0" in the total
box if there is none. Select the type of additional income or financial support that you receive and provide documentation.
Parental Support

Unemployment

Spousal Support (Alimony)

Social Security Benefits

Child Support

Veteran's Benefits

Educational Stipends

Financial Support From
Adult Children,
Dependents, Other People
Living in the Household

Royalties
Pensions
7.

Other (Explain)

Total Household Income (add the amounts from Item Numbers 4., 5., and 6.)

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Part 3. Household Income (continued)
8.

Has anything changed since the date you filed your Federal tax returns? (For example, your marital status,
income, or number of dependents.)

Yes

No

If you answered "Yes" to Item Number 8., provide an explanation below. Provide documentation if available.

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Part 4. Requestor's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-942 Instructions before completing this part.

Each person applying for a reduced fee must complete, sign, and date Form I-942 and provide the required documentation. This
includes family members identified in Part 2., Item Number 1. Signature fields for family members are at the end of this part. A
legal guardian may sign the request on behalf of the applicant. USCIS rejects any Form I-942 that is not signed by all individuals
requesting a reduced fee and may deny a request that does not provide the required documentation. If the information provided by the
requestor in Part 4. is not applicable to a family member identified in Part 2., that individual should complete Part 5.

Requestor's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Requestor's Statement Regarding the Interpreter
A.

I can read and understand English, and I have read and understand every question and instruction on this request, and my
answer to every question.

B.

The interpreter named in Part 6. read to me every question and instruction on this request, and my answer to every
question in
, a language in which I am fluent,
and I understood everything.

2.

Requestor's Statement Regarding the Preparer

At my request, the preparer named in Part 7.,
prepared this request for me based only upon information I provided or authorized.

,

Requestor's Contact Information
3.

Requestor's Daytime Telephone Number

5.

Requestor's Email Address (if any)

4.

Requestor's Mobile Telephone Number (if any)

Requestor's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this request, in supporting documents, and in my USCIS records to other entities
and persons where necessary for the administration and enforcement of U.S. immigration laws.
Form I-942 12/23/16 N

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Part 4. Requestor's Statement, Contact Information, Certification, and Signature (continued)
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my request;
2) I understood all of the information contained in, and submitted with, my request; and
3) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury, that I provided or authorized all of the information in my request, I understand all of the
information contained in, and submitted with, my request, and that all of this information is complete, true, and correct.

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Requestor's Signature
6.

Requestor's Signature

Date of Signature (mm/dd/yyyy)

Family Members' Signatures

NOTE: Each family member must type or print their full name and sign in the spaces below. You can find additional family
members' signature spaces in Item Numbers 7. - 10. below. All family members identified in Part 2., Item Number 1. must sign
and date Form I-942.
I certify that the information provided by the requestor in Part 4. applies to me.
7.

Family Member 1

Family Member's Name

Family Member's Signature

8.

Family Member 2

Date of Signature (mm/dd/yyyy)

Family Member's Name

Family Member's Signature

9.

Date of Signature (mm/dd/yyyy)

Family Member 3
Family Member's Name

Family Member's Signature

Date of Signature (mm/dd/yyyy)

10. Family Member 4
Family Member's Name

Family Member's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL REQUESTORS: If you do not completely fill out this request or fail to submit required documents listed in the
Instructions, USCIS may deny your request.

Form I-942 12/23/16 N

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Part 5. Family Member's Statement, Contact Information, Certification, and Signature
NOTE: Read the information on penalties in the Penalties section of the Form I-942 Instructions before completing this part.
If the information provided by the requestor in Part 4. is not applicable to a family member identified in Part 2., Item Number 1, (for
example, the family member used an interpreter or speaks a different language) that individual should complete Part 5. USCIS rejects
any Form I-942 that is not signed by all individuals requesting a reduced fee.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.

Family Member's Statement Regarding the Interpreter for:
A.

I can read and understand English, and have read and understand every question, instruction, and answer on this request.

B.

The interpreter named in Part 6. has also read to me every question, instruction, and answer on this request in

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, a language in which I am fluent. I understand
every question and instruction on this request as translated to me by my interpreter, and have provided complete, true,
and correct responses in the language indicated above.
2.

Family Member's Statement Regarding the Preparer for:
I have requested the services of and consented to
who

is

,

is not an attorney or accredited representative, preparing this request for me.

Family Member's Contact Information
3.

Family Member's Daytime Telephone Number

5.

Family Member's Email Address (if any)

4.

Family Member's Mobile Telephone Number (if any)

Family Member's Certification

I certify, under penalty of perjury, that the information in my request and any document submitted with my request were provided by
me and are complete, true, and correct.
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date.

Family Member's Signature
6.

Family Member's Signature

Date of Signature (mm/dd/yyyy)

NOTE TO ALL FAMILY MEMBERS: If you do not completely fill out this request or fail to submit required documents listed in
these Instructions, USCIS may deny your request.

Form I-942 12/23/16 N

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Part 6. Interpreter's Contact Information, Certification, and Signature
1.

Did any person filing this request use an interpreter? Yes, (complete this section). No, (skip to Part 7.)

Yes

No

2.

Was the same interpreter used for all individuals requesting a reduced fee (as listed in Part 2.)

Yes

No

NOTE for Family Members: If you used a different interpreter than the one used by the requestor, make additional copies of Part 6.,
provide the following information, indicate the family member for whom he or she interpreted, and include the pages with your
completed Form I-942.
Provide the following information about the interpreter.

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Interpreter's Full Name
3.

Interpreter's Family Name (Last Name)

4.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

Interpreter's Mailing Address
5.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
6.

Interpreter's Daytime Telephone Number

8.

Interpreter's Email Address (if any)

7.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
, which is the same language
specified in Part 4., Item B. in Item Number 1., and I have read to this requestor in the identified language every question and
instruction on this request and his or her answer to every question. The requestor informed me that he or she understands every
instruction, question, and answer on the request, including the Requestor's Certification, and has verified the accuracy of every
answer.

Interpreter's Signature
9.

Interpreter's Signature

Form I-942 12/23/16 N

Date of Signature (mm/dd/yyyy)

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Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor
1.

Did any person prepare this request on your behalf? Yes, (complete this section). No, (skip).

Yes

No

2.

Was the same preparer used for all individuals requesting a reduced fee (as listed in Part 2.)

Yes

No

NOTE for Family Members: If you used a different preparer than the one used by the requestor, provide the following information,
and include the pages with your completed Form I-942.
Provide the following information about the preparer.

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Preparer's Full Name
3.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

4.

Preparer's Business or Organization (if any)

Preparer's Mailing Address
5.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
6.

Preparer's Daytime Telephone Number

8.

Preparer's Email Address (if any)

7.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
9.

A.

I am not an attorney or accredited representative but have prepared this request on behalf of the
requestor and with the requestor’s consent.

B.

I am an attorney or accredited representative and my representation of the requestor in this case
extends
does not extend beyond the preparation of this request.
NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed
Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or G-28I, Notice
of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States,
with this request.

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Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor (continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this request at the request of the requestor. The requestor then
reviewed this completed request and informed me that he or she understands all of the information contained in, and submitted with,
his or her request, including the Requestor's Certification, and that all of this information is complete, true, and correct. I completed
this request based only on information that the requestor provided to me or authorized me to obtain or use.

Preparer's Signature
8.

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Preparer's Signature

Form I-942 12/23/16 N

Date of Signature (mm/dd/yyyy)

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Part 8. Additional Information
If you need extra space to provide any additional information within this request, use the space below. If you need more space than
what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper. Type or
print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to
which your answer refers.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

A. Page Number

D.

5.

A. Page Number

D.

6.

A. Page Number

Given Name (First Name)

Middle Name

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B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

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