Current Page Number and
Section
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Current Text
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Proposed
Text
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Page 1, Part 1. Basis
for Your Request (Each
basis is further explained in the Specific
Instructions section
of the Form I-219 Instructions)
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[Page 1]
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 11. Additional Information. Complete and
submit as many copies of Part 11., 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. [ ] 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. - 10.)
2. [ ] My household income
is at or below 150 percent of the Federal Poverty Guidelines.
(Complete Parts 2. - 3., Part 5., and 7.
- 10.)
3. [ ] I have a financial
hardship. (Complete Parts 2. - 3. and Parts 6.
- 10.
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[Page 1]
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?
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Page 1-2, Part 2.
Information About You (Requestor)
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[Page 1]
Part 2. Information About You
(Requestor)
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)
Given Name (First Name)
Middle Name
2. Other Names Used (if any)
List all other names you have used,
including nicknames, aliases, and maiden name.
Family Name (Last Name)
Given Name (First Name)
Middle Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
3. Alien Registration
Number (A-Number) (if any)
4. USCIS Online Account
Number (if any)
5. Date of Birth
(mm/dd/yyyy)
6. U.S.
Social Security Number (if any)
[Page 2]
7. Marital Status
[ ] Single, Never Married
[ ] Married
[ ] Divorced
[ ] Widowed
[ ] Marriage Annulled
[ ] Separated
[ ] Other (Explain)
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[Page 1]
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.
Check here if you are a parent or legal guardian filing on
behalf of the person seeking the fee waiver.
2.
Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
3.
Other Names Used (if any)
List all other names you have used,
including nicknames, aliases, and maiden name.
Family Name (Last Name)
Given Name (First Name)
Middle Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
4.
Alien Registration Number (A-Number) (if any)
5.
USCIS Online Account Number (if any)
6.
Date of Birth (mm/dd/yyyy)
7.
U.S. Social Security Number (if any)
[Page 2]
8.
Marital Status
[ ] Single, Never Married
[ ] Married
[ ] Divorced
[ ] Widowed
[ ] Marriage Annulled
[ ] Separated
[ ] Other
(Explain)
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Page 2, Part 4.
Means-Tested Benefits
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[Page 2]
Part 4. Means-Tested Benefits
If you selected Item Number 1.
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.
[Table, Means-Tested Benefit
Recipients; 6 columns, 4 rows]
Columns: Full Name of Person
Receiving the Benefit, Relationship
to You, Name of Agency Awarding Benefit, Type of
Benefit, Date Benefit was Awarded, Date Benefit Expires (or
must be renewed)
|
Part 4. Means-Tested Benefits
If you selected Item Number 1A.
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.
[Table]
Means-Tested Benefit Recipients
Full Name of Person Receiving the
Benefit
Relationship to You
Name of Agency Awarding Benefit
Type of Benefit
Date Benefit was Awarded
Date Benefit Expires (or must
be renewed)
Full Name of Person Receiving the
Benefit
Relationship to You
Name of Agency Awarding Benefit
Type of Benefit
Date Benefit was Awarded
Date Benefit Expires (or must
be renewed)
Full Name of Person Receiving the
Benefit
Relationship to You
Name of Agency Awarding Benefit
Type of Benefit
Date Benefit was Awarded
Date Benefit Expires (or must
be renewed)
Full Name of Person Receiving the
Benefit
Relationship to You
Name of Agency Awarding Benefit
Type of Benefit
Date Benefit was Awarded
Date Benefit Expires (or must
be renewed)
Full Name
of Person Receiving the Benefit
Relationship
to You
Name of
Agency Awarding Benefit
Type of
Benefit
Date
Benefit was Awarded
Date
Benefit Expires (or must be
renewed)
Full Name
of Person Receiving the Benefit
Relationship
to You
Name of
Agency Awarding Benefit
Type of
Benefit
Date
Benefit was Awarded
Date
Benefit Expires (or must be
renewed)
Full Name
of Person Receiving the Benefit
Relationship
to You
Name of
Agency Awarding Benefit
Type of
Benefit
Date
Benefit was Awarded
Date
Benefit Expires (or must be
renewed)
Full Name
of Person Receiving the Benefit
Relationship
to You
Name of
Agency Awarding Benefit
Type of
Benefit
Date
Benefit was Awarded
Date
Benefit Expires (or must be
renewed)
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Page 2-4, Part 5. Income
at or Below 150 Percent of the Federal Poverty Guidelines
|
[Page 2]
Part 5. Income at or Below 150
Percent of the Federal Poverty Guidelines
If you selected Item Number 2.
in Part 1., complete this section.
Your Employment Status
1. Employment Status
[ ] Employed (full-time, part-time,
seasonal, self-employed)
[ ] Unemployed or Not Employed
[ ] Retired
[ ] Other (Explain)
[Page 3]
2. If you are currently
unemployed, are you currently receiving unemployment benefits?
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?
A. If you answered “No”
to Item Number 3., does your spouse provide any financial
support to your household?
Your Household Size
4. Are you the person
providing the primary financial support for your household?
Yes
No
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.
[Table, Household Size; 6
columns, 5 rows]
Columns: Full Name, Date
of Birth, Relationship to You (first row, Self),
Married, Full-Time Student, Is any income earned
by this person counted towards the household income?
Final Row: 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.
5. Your Annual Income
6. Annual Income of All
Family Members
Provide the annual 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
Provide the total annual amount you
receive in additional income or financial support from a source
outside of your household. (Do not include the amount provided in
Item Numbers 5. or 6.) 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 there are none. Select the type of additional
income or financial support that you receive and provide
documentation.
[ ] Parental Support
[ ] Educational Stipends
[ ] Unemployment Benefits
[ ] Financial Support From Adult
Children, Dependents, Other People Living in the Household
[ ] Spousal Support (Alimony)
[ ] Royalties
[ ] Social Security Benefits
[ ] Child Support
[ ] Pensions
[ ] Veteran's Benefits
[ ] Other (Explain)
[new]
[Page 4]
8. Total 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.)
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.
|
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)
[ ] Unemployed or Not Employed
[ ] Retired
[ ] Other (Explain)
[Page 3]
2. If you are currently
unemployed, are you currently receiving unemployment benefits?
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?
Yes/No
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.
[Table]
Household Size
Full Name
Date of Birth
Relationship to You
Married
Full-Time Student
Is any income earned by this
person counted towards the household income?
Full Name
Date of Birth
Relationship to You
Married
Full-Time Student
Is any income earned by this
person counted towards the household income?
Full Name
Date of Birth
Relationship to You
Married
Full-Time Student
Is any income earned by this
person counted towards the household income?
Full Name
Date of Birth
Relationship to You
Married
Full-Time Student
Is any income earned by this
person counted towards the household income?
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
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
[deleted]
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.
[Table, 12
rows, 2 columns: Type of Income,
Annual Amount (in
dollars); last row, Total
Additional Income and Financial Support]
[1st
column should read:
Parental
Support, Yes/No
Spousal
Support (Alimony), Yes/No
Child Support,
Yes/No
Educational
Stipends, Yes/No
Royalties,
Yes/No
Pensions,
Yes/No
Unemployment
Benefits, Yes/No
Social
Security Benefits, Yes/No
Veteran's
Benefits, Yes/No
Financial
Support from Adult Children, Dependents, Other People Living in
the Household, Yes/No
Other, Yes/No,
Explanation]
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.)
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.
|
Page 4-5 Part 6.
Financial Hardship
|
[Page 4]
Part 6. Financial Hardship
If you selected Item Number 3.
in Part 1., complete this section.
1. 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.
2. 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.)
[Table, Assets; 2 columns]
Columns: Type of Asset, Value
(U.S. Dollars)
Final Row: Total Value of Assets
[Page 5]
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
[ ] Other
[ ] Food
[ ] Car Payment
[ ] Utilities
[ ] Commuting Cost
[ ] Child and/or Elder Care
[ ] Medical Expenses
[ ] Insurance
[ ] School Expenses
|
Part 6. Financial Hardship
If you selected Item Number 1.C.
in Part 1., complete this section.
1. 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.).
2. 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.)
[Table]
Assets
Type of Asset
Value (U.S. Dollars)
Type of Asset
Value (U.S. Dollars)
Type of Asset
Value (U.S. Dollars)
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
[ ] Other
[ ] Food
[ ] Car Payment
[ ] Utilities
[ ] Commuting Cost
[ ] Child and/or Elder Care
[ ] Medical Expenses
[ ] Insurance
[ ] School Expenses
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Page 5-6, Part 7.
Requestor’s Statement, Contact Information, Certification,
and Signature
|
[Page 5]
Part 7. Requestor's Statement,
Contact Information, Certification, and Signature
NOTE: Read the Penalties
section of the Form I-912 Instructions before completing this
part.
Each person applying for a fee
waiver request must complete, sign, and date Form I-912 and
provide the required documentation. This includes family members
identified in Part 3. Signature fields for family members
are at the end of this part. 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 by all
individuals requesting a fee waiver and may deny a request that
does not provide required documentation.
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 9. read to me every question and instruction on this
request and my answer to every question in [fillable field], a
language in which I am fluent, and I understood everything.
2. Requestor's Statement
Regarding the Preparer (if applicable)
At my request, the preparer named in
Part 10., [fillable field] ,
prepared this request for me based only upon information I
provided or authorized.
Requestor's Contact
Information
3. Requestor's Daytime
Telephone Number
4. Requestor's Mobile
Telephone Number (if any)
5. Requestor's Email Address
(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.
[new]
[Page 6]
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.
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
Numbers7. - 10. Below. All family members identified in Part
3. must sign and date Form I-912.
I certify that the information
provided by the requestor in Part 7. applies to me.
7. Family Member 1
Family Member's Name
Family Member's Signature
Date of Signature (mm/dd/yyyy)
8. Family Member 2
Family Member's Name
Family Member's Signature
Date of Signature (mm/dd/yyyy)
9. 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)
11. Family Member 5
Family Member's Name
Family Member's Signature
Date of Signature (mm/dd/yyyy)
|
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.
[deleted]
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 8. read to me
every question and instruction on this request and my answer to
every question in [fillable field], a language in which I am
fluent, and I understood everything.
2. Requestor's Statement
Regarding the Preparer (if applicable)
At my request, the preparer named in
Part 9., [fillable
field] , prepared this request for me based only upon information
I provided or authorized.
Requestor's Contact
Information
3. Requestor's Daytime
Telephone Number
4. Requestor's Mobile
Telephone Number (if any)
5. Requestor's Email Address
(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.
[Page 6]
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.
[deleted]
|
Page 7, Part 8. Family
Member’s Statement, Contact Information, Certification, and
Signature
|
[Page 7]
Part 8. Family Member's
Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties
section of the Form I-912 Instructions before completing this
part.
If the information provided by the
requestor in Part 7. is not applicable to a family member
identified in Part 3., (for example, the family member used an
interpreter or speaks a different language) that individual should
complete Part 8. USCIS rejects any Form I-912 that is not
signed by all individuals requesting a fee waiver.
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 [fillable field]
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 9. read to me every question and instruction on this
request and my answer to every question in [fillable field]
, a language in which I am fluent, and I understood
everything.
2. Family Member's Statement
Regarding the Preparer for [fillable field]
At my request, the preparer named in
Part 10., [fillable field], prepared this request for me based
only upon information I provided or authorized.
Family Member's Contact
Information
3. Family Member's Daytime
Telephone Number
4. Family Member's Mobile
Telephone Number (if any)
5. Family Member's Email
Address (if any)
Family Member'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.
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 the Instructions, USCIS may deny your
request.
|
[deleted]
|
Page 8, Part 9.
Interpreter’s Contact Information, Certification, and
Signature
|
[Page 8]
Part 9. 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 10.)
2. Was the same interpreter
used for all individuals requesting a fee waiver (as listed in
Part 3.)?
NOTE for Family Members: If
you used a different interpreter than the one used by the
requestor, make additional copies of Part 9., provide the
following information, indicate the family member for whom he or
she interpreted, and include the pages with your completed Form
I-912.
Provide the following information
about the interpreter for [fillable field]
Interpreter's Full Name
3. Interpreter's Family Name
(Last Name)
Interpreter's Given Name (First
Name)
4. Interpreter's Business or
Organization Name (if any)
Interpreter's Mailing Address
(USPS ZIP Code Lookup)
5. Street Number and Name
Apt Ste Flr
City or Town
State
ZIP Code
Province
Postal Code
Interpreter's Contact
Information Country
6. Interpreter's Daytime
Telephone Number
7. Interpreter's Mobile
Telephone Number (if any)
8. Interpreter's Email
Address (if any)
Interpreter's Certification
I certify, under penalty of perjury,
that:
I am fluent in English and [fillable
field], 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
9. Interpreter's Signature
Date of Signature (mm/dd/yyyy)
|
Part 8.
Interpreter's Contact Information, Certification, and Signature
[deleted]
Provide the following information
about the interpreter.
Interpreter's Full Name
1.
Interpreter's Family Name (Last Name)
Interpreter's Given Name (First
Name)
2.
Interpreter's Business or Organization Name (if any)
Interpreter's Mailing Address
(USPS ZIP Code Lookup)
3.
Street Number and Name
Apt. Ste. Flr. Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Interpreter's Contact
Information Country
4.
Interpreter's Daytime Telephone Number
5.
Interpreter's Mobile Telephone Number (if any)
6.
Interpreter's Email Address (if any)
Interpreter's Certification
I certify, under penalty of perjury,
that:
I am fluent in English and [fillable
field], 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
Date of Signature (mm/dd/yyyy)
|
Page 9-10, Part 10.
Contact Information, Declaration, and Signature of the Person
Preparing this Request, if Other Than the Requestor
|
[Page 9]
Part 10. 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
2. Was the same preparer
used for all individuals requesting a fee waiver (as listed in
Part 3.)?
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-912.
Provide the following information
about the preparer for [fillable field]
Preparer's Full Name
3. Preparer's Family Name
(Last Name)
Preparer's Given Name (First Name)
4. Preparer's Business or
Organization Name (if any)
Preparer's Mailing Address
5. Street Number and Name
Apt Ste Flr
City or Town
State
ZIP Code
Province
Postal Code
Preparer's Contact Information
6. Preparer's Daytime
Telephone Number
7. Preparer's Mobile
Telephone Number (if any)
8. Preparer's Email Address
(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 application.
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.
[Page 10]
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
10. Preparer's Signature
Date of Signature (mm/dd/yyyy)
|
Part 9.
Contact Information, Declaration, and Signature of the Person
Preparing this Request, if Other Than the Requestor
[deleted]
Provide the following information
about the preparer (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)
Preparer's Mailing Address
3.
Street Number and Name
Apt Ste Flr Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
4.
Preparer's Daytime Telephone Number
5.
Preparer's Mobile Telephone Number (if any)
6.
Preparer's Email Address (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 application.
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.
[Page 10]
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
Date of Signature
(mm/dd/yyyy)
|
Page 11, Part 11.
Additional Information
|
[Page 11]
Part 11. 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)
Given Name (First Name)
Middle Name
2. A-Number (if any)
3. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
4. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
5. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
6. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
|
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)
Given Name (First Name)
Middle Name
2. A-Number (if any)
3. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
4. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
5. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
6. A. Page Number
B. Part Number
C. Item Number
D. [Fillable field]
|