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: 10/31/2021

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

USCIS Field Office

USCIS Service Center

Fee Waiver Approved

Fee Waiver Rejected

Fee Waiver Approved

Fee Waiver Rejected

Date:______________

Date:______________

Date:______________

Date:______________

► 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 7. Additional Information.
Complete and submit as many copies of Part 7., as necessary, with your request.

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Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been married and the
question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise directed. If your answer to a question
which requires a numeric response is zero or none (for example, “How many children do you have?” or “How many times have you
departed the United States?”), type or print “None” unless otherwise directed.

Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
1.

Select a basis for which you may qualify and provide supporting documentation for any basis you select.

A. My annual household income is at or below 125 percent of the Federal Poverty Guidelines and I am applying for, have
status as, or have been approved as one of the following:
A battered spouse or child of a lawful permanent resident or U.S. citizen or derivative of such individual under INA
240A(b)(2)

A T nonimmigrant

A U nonimmigrant

A VAWA self -petitioner or his or her derivative
Temporary Protected Status (TPS)

A Special Immigrant Juvenile (SIJ), and I am currently placed in out-of-home care under the supervision of a
juvenile court or a state child welfare agency
Applicant as an Afghan or Iraqi Translator or Interpreter, Iraqi National employed by or on behalf of the U.S.
Government, or Afghan National employed by or on behalf of the U.S. government or employed by the International
Security Assistance Forces.

Provide the Receipt Number for the category you indicated in Item Number 1.A.
►
B. I am impacted by an emergent circumstance or major natural disaster declaration posted to www.uscis.gov providing relief
from USCIS filing fees and my documented annual household income is at or below 125 percent of the Federal Poverty
Guidelines (FPG), and I am not seeking an immigration benefit for which I would be subject to the public charge ground
of inadmissibility, the affidavit of support requirement under INA 212(a)(4)(C) or (D), and I am not already a sponsored
immigrant as defined by 8 CFR 213a.1.
2.

What is your current immigrant or nonimmigrant status?

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Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions) (continued)
3.

For what application(s) or petition(s) are you applying for a fee waiver?

Part 2. Information About You (Requestor)

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Provide information about yourself if you are the person requesting a fee waiver for a petition or application you are filing. If you are
the parent or legal guardian filing on behalf of 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 form.
1.

Full Name

Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Other Names Used

List all other names you have used, including nicknames, aliases, and maiden name.
Family Name (Last Name)

3.

Given Name (First Name)

Alien Registration Number (A-Number)
► A-

5.

Date of Birth (mm/dd/yyyy)

7.

Marital Status
Single, Never Married

4.

Middle Name

USCIS Online Account Number
►

6.

U.S. Social Security Number
►

Married

Divorced

Widowed

Marriage Annulled

Separated

Other (Explain)

Part 3. Household Gross Income

For information regarding required documentation, see the instructions.
If you are an SIJ placed in out-of-home care under the supervision of a juvenile court or state child welfare agency, you do not need to
complete Part 3.

Your Employment Status
1.

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

Form I-912 10/15/19

Unemployed or
Not Employed

Retired

Other (Explain)

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Part 3. Household Gross Income (continued)
2.

If you are currently unemployed, are you currently receiving unemployment benefits?

Yes

No

Yes

No

A. Date you became unemployed (mm/dd/yyyy)

Information About Your Spouse
3.

If you are married (including separated, but not divorced), does your spouse live in your household?
Yes (add your spouse to the table below and provide
his or her income in Item Number 7. below)

No

N/A - not married

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 8. below)

No

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Your Household Size
4.

Are you the person providing the primary financial support (head of household) for your household?

If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below and also provide
your gross income in Item Number 6. 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 Gross Size

Full
Name

Date of
Birth

Relationship
to You
Self

Full-Time
Student

Married

Is any income earned by this
person counted towards the
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 Gross Household Income
5.

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

Yes

If you answered “No” to Item Number 5., provide an answer to Item C.
A. Did any of your household members file a tax return for the last year?
Yes

No

If you answered “No” to Item A., provide an answer to Item B. and C.
B. If no, which household member(s) did not file a tax return?

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Part 3. Household Gross Income (continued)
C. If you or your household member(s) did not file a tax return, select the reason for not filing and provide an explanation.
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:

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Provide information about your gross income and the income of all family members counted as part of your household. You must list
all amounts in U.S. dollars.
6.

Your Annual Gross Income

$

7.

Annual Gross Income of All Family Members Counted as Part of Your Household (Do not include the
amount provided in Item Number 6.)

$

8.

Total Additional Income or Financial Support (Do not include the amount provided in Item Number
6. or 7.)

$

If you received additional income on a continuing basis (e.g., monthly or annually) 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 Stipend

Yes

No

Royalties

Yes

No

Yes

No

Unemployment Benefit

Yes

No

Social Security Benefit

Yes

No

Veteran's Benefit
Financial Support from Adult
Child(ren), Dependent, Other Person
Living in the Household
Other: (Explanation Below)

Yes

No

Yes

No

Yes

No

Pension

Total Additional Income and Financial Support

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Part 3. Household Gross Income (continued)
9.

Total Annual Gross Household Income (add the amounts from Item Numbers 6., 7., and 8.)

$

10. Has any information you reported in the last income tax return changed since the date you filed your
Federal income tax return? (For example, your marital status, income, or number of dependents.)

Yes

No

If you answered "Yes" to Item Number 10., 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.

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11. If you already have or are applying for VAWA benefits or T or U nonimmigrant status, are you unable to
obtain documentation of your income or a household member's income?

Yes

No

If you answered “Yes” to Item Number 11., provide an explanation below explaining your inability to obtain the required
documentation. Provide any other available documentation of your and your household's income. 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.

Part 4. Requestor's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.

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

2.

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 5. 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.

Requestor's Statement Regarding the Preparer (if applicable)

At my request, the preparer named in Part 6.,
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)

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4.

Requestor's Mobile Telephone Number (if any)

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Part 4. Requestor's Statement, Contact Information, Certification, and Signature (continued)
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.
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.

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Requestor's Signature
7.

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 reject or deny your request.

Part 5. 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)

Interpreter's Mailing Address
3.

(USPS ZIP Code Lookup)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

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5.

Interpreter's Mobile Telephone Number (if any)

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Part 5. Interpreter's Contact Information, Certification, and Signature (continued)
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
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

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Part 6. 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)

Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

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
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 6. 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.

Preparer's Signature

Date of Signature (mm/dd/yyyy)

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Part 7. 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. Include
your name and A-Number 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

3.

A. Page Number

D.

4.

5.

6.

B. Part Number

C. Item Number

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A. Page Number

D.

Middle Name

► A-

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

D.

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