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 12/31/2023

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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:______________

► 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 Edition 12/02/21

Unemployed or
Not Employed

Retired

Other (Explain)

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

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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?

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.)

Form I-942 Edition 12/02/21

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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

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

Part 4. Requestor's Contact Information, Certification, and Signature
Requestor's Contact Information

Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1.

Requestor's Daytime Telephone Number

3.

Requestor's Email Address (if any)

2.

Requestor's Mobile Telephone Number (if any)

Requestor's Certification and Signature

I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my request, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 5.,
understood, all of the responses and information contained in, and submitted with, my request and that all of the responses and the
information are complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records
that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
4.

Requestor's Signature

Form I-942 Edition 12/02/21

Date of Signature (mm/dd/yyyy)

Page 3 of 5

Part 5. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name

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1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name

Interpreter's Given Name (First Name)

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification and Signature

,

I certify, under penalty of perjury, that I am fluent in English and

and I have interpreted every question on the request and Instructions and interpreted the requestor's answers to the questions in that
language, and the requestor informed me that they understood every instruction, question, and answer on the request.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

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)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this request for the requestor at their request and with express consent and that all of
the responses and information contained in and submitted with the request are complete, true, and correct and reflects only
information provided by the requestor. The requestor reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the request.
6.

Preparer's Signature

Form I-942 Edition 12/02/21

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. 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.

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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

Given Name (First Name)

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

Middle Name

D.

6.

A. Page Number

D.

Form I-942 Edition 12/02/21

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