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: 09/30/2024

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 10. Additional Information.
Complete and submit as many copies of Part 10., 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.A.

I am, my spouse is, or the head of household living in my household is currently receiving a means-tested benefit.
(Complete Parts 2. - 4. and Parts 7. - 9.)

B.

My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part
5., and Parts 7. - 9.)

C.

I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 9.)

2.

What is your current immigrant or nonimmigrant status?

Part 2. Information About You (Requestor)
Provide information about yourself if you are the person requesting a fee waiver for a petition or application that you are filing for
yourself. If you are the parent or legal guardian filing on behalf of a child or person with a developmental or mental impairment,
provide information about the child or person for whom you are filing this form.
1.
2.

Check here if you are a parent or legal guardian filing on behalf of the person seeking the fee waiver.
Full Name
Family Name (Last Name)

3.

Given Name (First Name)

Middle Name

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

4.

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

Form I-912 Edition 09/03/21

Given Name (First Name)

5.

Middle Name

USCIS Online Account Number (if any)
►
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Part 2. Information About You (Requestor) (continued)
6.

Date of Birth (mm/dd/yyyy)

8.

Marital Status
Single, Never Married

7.

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

Married

Divorced

Widowed

Marriage Annulled

Separated

Other (Explain)

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Part 3. Applications and Petitions for Which You Are Requesting a Fee Waiver
1.

In the table below, add the form numbers of the applications and petitions for which you are requesting a fee waiver.

Applications or Petitions for You and Your Family Members

Full Name

A-Number (if any)

Date of Birth

Relationship to You

Forms Being Filed

AAAA-

Total Number of Forms (including self)

Part 4. Means-Tested Benefits

If you selected Item Number 1.A. in Part 1., complete this section.
1.

If you, your spouse, or the head of household (including parent if the child is under 21 years of age) living with you is receiving
any means-tested benefits, list the information in the table below and attach supporting documentation. 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 if he or she is receiving a means-tested benefit.

Means-Tested Benefit Recipients

Full Name of Person
Receiving the Benefit

Form I-912 Edition 09/03/21

Relationship
to You

Name of Agency
Awarding Benefit

Type of
Benefit

Date Benefit Date Benefit Expires
was Awarded (or must be renewed)

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Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines
Provide information about your adjusted gross income. See Instructions for more details.
If you selected Item Number 1.B. in Part 1., complete this section.

Your Employment Status
1.

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

2.

Unemployed or
Not Employed

Other (Explain)

Retired

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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 or separated, does your spouse live in your household?

Yes (add your spouse to the table below and provide his or her gross income in Item Number 7. 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 8. below)
No

Your Household Size
4.

Are you the person providing the primary financial support 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. 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
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 Household Income
Provide information about your adjusted gross income and the adjusted gross income of all family members counted as part of your
household. You must list all amounts in U.S. dollars.
5.

Your Annual Income

Form I-912 Edition 09/03/21

$

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Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)
6.

Annual Income of All Family Members
Provide the annual adjusted gross income of all family members counted as part of your household as listed in Item Number 4.
(Do not include the amount provided in Item Number 5.)
$

7.

$

Total Additional Income or Financial Support

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. For types of additional income, see Instructions.
Type of Income
Parental Support

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Annual Amount (in dollars)

Yes

No

Spousal Support (Alimony)

Yes

No

Royalties

Yes

No

Yes

No

Unemployment Benefits

Yes

No

Veteran's Benefits

Yes

No

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

Yes

No

Other (Explain)

Yes

No

Pensions

Total Additional Income and Financial Support
8.

Total Adjusted Gross Household Income (add the amounts from Item Numbers 5., 6., and 7.)

9.

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 9., 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 USCIS to consider.

Form I-912 Edition 09/03/21

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Part 6. Financial Hardship
If you selected Item Number 1.C. in Part 1., complete this section.
1.

2.

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. 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, and homelessness. This
may include homelessness, major medical debt for yourself or a family member, and natural disasters declaration posted to
www.uscis.gov (Part 1., Item A. in Number 2.).

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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 Edition 09/03/21

Other

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Part 7. Requestor's Statement, Contact Information, Certification, and Signature
The person whose information is provided in Part 2. may sign on behalf of the entire household. If the person listed in Part 2. is
under 14 years of age, a parent or legal guardian may sign on their behalf.
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 8. 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.

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Requestor's Statement Regarding the Preparer (if applicable)

At my request, the preparer named in Part 9.,
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.
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.
I certify that the information provided by the requestor in Part 7. applies to the household members identified in Part 3.
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 Edition 09/03/21

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Part 8. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.

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 7., 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 Applicant's Certification, and has verified the accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Form I-912 Edition 09/03/21

Date of Signature (mm/dd/yyyy)

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Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor
Provide the following information about the preparer for (if applicable)

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)

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Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

ZIP Code

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
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.

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 Applicant'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 Edition 09/03/21

Date of Signature (mm/dd/yyyy)

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Part 10. 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 (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.

Given Name (First Name)

Middle Name

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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 Edition 09/03/21

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