Form I-912 Request for Fee Waiver

Request for Fee Waiver

USCIS
Form I-912

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

OMB No. 1615-0116
Expires: 03/31/2020

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

USCIS Field Office

USCIS Service Center

Fee Waiver Approved

Fee Waiver Denied

Fee Waiver Approved

Fee Waiver Denied

Date:______________

Date:______________

Date:______________

Date:______________

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► START HERE - Type or print in black ink.

If you need extra space to complete any section of this request or if you would like to provide additional
information about your circumstances, use the space provided in Part 8. Additional Information.
Complete and submit as many copies of Part 8., as necessary, with your request.

Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
Select at least one basis or more for which you may qualify and provide supporting documentation for any basis you select. You only
need to qualify and provide documentation for one basis for U.S. Citizenship and Immigration Services (USCIS) to grant your fee
waiver. If you choose, you may select more than one basis; you must provide supporting documentation for each basis you want
considered.
1.

My household income is at or below 150 percent of the Federal Poverty Guidelines (FPG). (Complete Parts 2. - 3., and
Parts 5. - 7.)

2.

I have a financial hardship. (Complete Part 2., and Parts 4. - 7.)

Part 2. Information About You (Requestor)

Provide information about yourself if you are requesting a fee waiver for a petition or application you are filing. If you are a parent or
legal guardian filing for a child or person with a physical disability or developmental or mental impairment, provide information about
the child or person for whom you are filing this request.
1.

Full Legal Name

Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Other Names Used (if any)
Provide all other names you have ever used, including aliases, maiden name, and nicknames.
Family Name (Last Name)

Given Name (First Name)

3.

Alien Registration Number (A-Number) (if any)
► A-

4.

USCIS Online Account Number (if any)
►

5.

Date of Birth (mm/dd/yyyy)

6.

U.S. Social Security Number (if any)
►

7.

Marital Status
Single, Never Married

Married

Divorced

Widowed

Middle Name

Marriage Annulled

Separated

Other (Explain)
Form I-912 03/13/18

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Part 2. Information About You (Requestor)
8.

List and provide the total number of applications and petitions for which you are requesting a fee waiver.
Form

Number

Total Number
9.

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Are you applying for or have status or a granted approval as a battered spouse of an A, G, E-3, or H nonimmigrants; a battered
spouse or child of a lawful permanent resident or U.S. citizen under INA section 240A(b)(2); a T nonimmigrant; a person with
Temporary Protected Status; a U nonimmigrant; or a VAWA self -petitioner?
Yes
No

A. Receipt Number (if applicable)
►

Part 3. Household Income
Your Employment Status
1.

Employment Status

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

Unemployed or Not Employed

Retired

Other (Explain)
2.

If you are currently unemployed, since when have you been unemployed (mm/dd/yyyy)?

A. If you are currently unemployed, are you currently receiving unemployment benefits?
Yes
No

Information About Your Spouse
3.

If you are married or separated, does your spouse live in your household?
Yes (add your spouse to the table below and provide his or her income in Item Number 9. below)
No
A. If you answered “No” to Item Number 3., does your spouse provide any financial support to your household?
Yes (provide financial support income in Item Number 10. below)
No

Your Household Size
4.

Are you the person providing the primary financial support for your household?
Yes
No

Form I-912 03/13/18

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Part 3. Household Income (continued)
If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below. Also provide
income in Item Number 8. below. If you answered “No” to Item Number 4., 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

Married

Full-Time Is any income earned by this
Student person counted towards the
household income?
Yes No
Yes
No

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Yes

No

Self

Total Household Size (including self)

Your Annual Household Income
5.

Did you file a federal tax return for the last year?
Yes
No

If you answered “No” to Item Number 5., provide an answer to Item Number 7.
6.

Did your household members file tax returns for the last year?
Yes
No

If you answered “No” to Item Number 6., provide an answer to Item Number 7.

If you answered “No” to Item Number 6., which household member(s) did not file a tax return?

7.

If you or your household member did not file a tax return for the last year, select the reason for not filing and provide an
explanation. See I-912 Instructions for required documentation.
I/we plan to file the tax return before the due date this year.
I/we are not required to file a tax return for the current or previous year.
I/we filed for an extension.
I/we are not going to file.
Explanation:

Form I-912 03/13/18

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Part 3. Household Income (continued)
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.
8.

Your Annual Income

$

9.

Annual Income of All Family Members Counted as Part of Your Household (Do not include the
amount provided in Item Number 8.)

$

10. Total Additional Income or Financial Support (Do not include the amount provided in Item
Numbers 8. or 9.)

$

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If you received additional income on a continuing monthly or annual basis for the most recent full year, and it is NOT listed in
your Federal tax return, provide the amount of additional income below (for example, child support). Attach evidence of the
additional income. You must add all of the additional income and financial support amounts and put the total amount in the space
provided. Type or print "0" in the total box if no additional income is received.
Type of Income

Annual Amount (in dollars)

Parental Support

Yes

No

Spousal Support (Alimony)

Yes

No

Child Support

Yes

No

Educational Stipends

Yes

No

Royalties

Yes

No

Yes

No

Unemployment Benefits

Yes

No

Social Security Benefits

Yes

No

Veteran's Benefits
Financial Support from Adult
Children, Dependents, Other People
Living in the Household
Other: (Explanation Below)

Yes

No

Yes

No

Yes

No

Pensions

Total Additional Income and Financial Support

11. Total Annual Household Income (add the amounts from Item Numbers 8., 9., and 10.)
12. 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 12., provide an explanation below. Provide documentation if available. You may also
use this space to provide any additional information about your circumstances that you would like U.S. Citizenship and
Immigration Services (USCIS) to consider.

Form I-912 03/13/18

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Part 4. Financial Hardship
If you selected Item Number 2. in Part 1., complete this section.
1.

2.

If you or any family members have a situation that has caused you to incur expenses, debts, or loss of income, describe the
situation in the box below. Specify the amounts of the expenses, debts, and income losses in as much detail as possible.
Examples may include medical expenses, job loss, eviction, victimization, and homelessness.

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If you have cash or assets that you can quickly convert to cash, list those in the table below. For example, bank accounts, stocks,
or bonds. (Do not include retirement accounts.)

Assets

Type of Asset

Value (U.S. Dollars)

Total Value of Assets
3.

Total Monthly Expenses and Liabilities

$

Provide the total monthly amount of your expenses and liabilities. You must add all of the expense and liability amounts and type
or print the total amount in the space provided. Type or print "0" in the total box if there are none. Select the types of expenses or
liabilities you have each month and provide evidence of monthly payments, where possible.
Rent and/or Mortgage

Loans and/or Credit Cards

Food

Car Payment

Utilities

Commuting Costs

Child and/or Elder Care

Medical Expenses

Insurance

School Expenses

Form I-912 03/13/18

Other

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Part 5. Requestor's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-912 Instructions before completing this section.
You must complete, sign, and date Form I-912 and provide the required documentation. If an individual is under 14 years of age, a
parent or legal guardian may sign the request on their behalf. USCIS rejects any Form I-912 that is not signed and may deny a request
that does not provide required documentation.
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.
B.

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.

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The interpreter named in Part 6. read to me every question and instruction on this request and my answer to every
question in
and I understood everything.

2.

, a language in which I am fluent,

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
and all of my records that USCIS may need to determine my eligibility for the immigration benefit that 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 law.
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.
WARNING: If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-912,
USCIS will deny your fee waiver request and may deny any other immigration benefit. In addition, you may face severe penalties
provided by law and may be subject to criminal prosecution.

Requestor's Signature
6.

Requestor'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-912 03/13/18

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

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

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Interpreter's Mailing Address
3.

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

ZIP Code

Country

Postal Code

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

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 5., 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
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

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

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Form I-912 03/13/18

Preparer's Given Name (First Name)

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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 Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

ZIP Code

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Country

Postal Code

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

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
does not extend beyond the preparation of this request.

extends

NOTE: If you are an attorney or accredited representative, you may need 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.

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.

Preparer's Signature

Form I-912 03/13/18

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; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

Middle Name

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A. Page Number

D.

Given Name (First Name)

A. Page Number

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.

Form I-912 03/13/18

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