I-912-019-INS-FeeRule-OPSReview-FR-01312024

Instructions for Request for Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-912

OMB No. 1615-0116
Expires 09/30/2024

What Is the Purpose of Form I-912?
You may request a fee waiver if you are unable to pay the filing fees or biometric services fees for an application or
petition that is eligible for a fee waiver. When you request a fee waiver, you must clearly demonstrate that you are unable
to pay the fees. For purposes of this form, the Requestor is the primary applicant or petitioner requesting the immigration
benefit and fee waiver. The Requestor can also be the parent or legal guardian of a child or person with a physical,
developmental, or mental disability who is the primary applicant or petitioner. If an individual is under 14 years of age, a
parent or legal guardian may sign the request on behalf of that person.

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Please note the Form I-912 must be submitted in the name of the primary applicant requesting the immigration benefit fee
and waiver.
You can find the list of applications and petitions that are eligible for a fee waiver at www.uscis.gov/I-912 or refer to
8 CFR 106.3(a)(3). For filing tips and additional information, see www.uscis.gov/feewaiver.
You do not need to submit Form I-912 for an application or petition that does not require a filing fee or if you qualify for
a fee exemption based on your immigration status. See Form G-1055, available at www.uscis.gov/forms, for specific
information about the fee exemptions available.
Forms Eligible for Fee Waiver

Below is a list of applications and petitions U.S. Citizenship and Immigration Services (USCIS) will consider for a fee
waiver and the conditions that must be met to be eligible for a fee waiver. Under current fee waiver regulations, USCIS
can only approve fee waivers for certain forms or certain filings of a particular form type, when fee waiver requirements
are met.
You may file this form to request a fee waiver for any of the following benefit requests or services:
•

Application to Replace Permanent Resident Card (Form I-90);

•

Application for Advance Permission to Return to Unrelinquished Domicile (Form I-191);

•

Petition to Remove the Conditions of Residence (Form I-751);

•

Application for Family Unity Benefits (Form I-817);

•

Application for Suspension of Deportation or Special Rule Cancellation of Removal (Form I-881) (pursuant to section
203 of Pub. L. 105–110);

•

Application to File Declaration of Intention (Form N-300);

•

Request for a Hearing on a Decision in Naturalization Proceedings (Form N-336) (under section 336 of the INA);

•

Application for Naturalization (Form N-400);

•

Application to Preserve Residence for Naturalization Purposes (N-470);

•

Application for Replacement Naturalization/Citizenship Document (N-565);

•

Application for Certificate of Citizenship (N-600); and

•

Application for Citizenship and Issuance of Certificate under section 322 of the Act (N-600K).

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For the following forms under certain conditions:
•

Petition for a CNMI-Only Nonimmigrant Transitional Worker, or an Application to Extend/Change Nonimmigrant
Status (Form I-539), only in the case of a noncitizen applying for CW-2 nonimmigrant status;

•

Application for Travel Document (Form I-131), when filed to request humanitarian parole;

•

Notice of Appeal or Motion (Form I-290B), when there is no fee for the underlying application or petition or when the
fee for the underlying application or petition may be waived;

•

Notice of Appeal of Decision Under Sections 245A or 210 of the Immigration and Nationality Act (Form I-694), if the
underlying application or petition was fee exempt, the filing fee was waived, or was eligible for a fee waiver;

•

Application for Employment Authorization (Form I-765), except persons filing under category (c)(33), Deferred
Action for Childhood Arrivals (DACA);

•

Petition for Nonimmigrant Worker (Form I-129) or Application to Extend/Change Nonimmigrant Status (Form I-539),
only in the case of an alien applying for E-2 CNMI Investor for an extension of stay;

•

Application for Temporary Protected Status, Form I-821, when filed as a first-time applicant; and

•

Application for Action on Approved Application or Petition, Form I-824, under 8 CFR 106.3(a)(3)(iii) only for VAWA
self-petitioners.

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For the following forms if the applicant is exempt from public charge ground of inadmissibility under INA section 212(a)
(4):
•

Application for Advance Permission to Enter as Nonimmigrant (Form I-192);

•

Application for Waiver for Passport and/or Visa (Form I-193);

•

Application to Register Permanent Residence or Adjust Status (Form I-485); and

•

Application for Waiver of Grounds of Inadmissibility (Form I-601).

If not otherwise fee exempt, you may apply for a fee waiver for ANY application or petition that is related to status as a:
1. Battered spouse of A, G, E-3, or H nonimmigrant;

2. Battered spouse or child of a lawful permanent resident or U.S. citizen under INA section 240A(b)(2);
3. T nonimmigrant;

4. Temporary Protected Status;
5. U nonimmigrant; or

6. VAWA self–petitioner and derivative(s);
7. Conditional permanent resident (CPR) filing a waiver of the joint filing requirement based on battery or extreme
cruelty;
8. Abused spouses and children adjusting status under the Cuban Adjustment Act (CAA) and Haitian Refugee
Immigration Fairness Act of 1998 (HRIFA);
9. Abused spouses and children seeking benefits under Nicaraguan Adjustment and Central American Relief Act
(NACARA);
10. Special Immigrant Juveniles;
11. Asylees; or
12. Refugees.

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You may not file Form I-912 if you are requesting consideration for DACA. There are no fee waivers for DACA. Fee
exemptions will be available in limited circumstances. See the Deferred Action for Childhood Arrivals Fee exemption
at www.uscis.gov/forms/forms-and-fees/guidance-exemption-fee-form-i-765-filed-request-considerationdeferredaction-childhood-arrivals for more details.

How to File Form I-912
You must file this fee waiver request with all applications and petitions for which you are requesting a fee waiver. If you
are filing joint forms that have fees (for example, I-485 and I-765), you only need to file one Form I-912. You do not have
to file a separate Form I-912 for the filing fee and the biometric services fee (if applicable).

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You may file one Form I-912 for all family-related applications or petitions filed at the same time. For example, if you file
Form I-765, Application for Employment Authorization, and your spouse and children are filing separate Form I-765s at
the same time, you only need to file one Form I-912 for all Form I-765s. You must send all forms together.

General Instructions

We provide free forms through the USCIS website. To view, print, or complete our forms, you should use the latest
version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not have internet
access, you may call the USCIS Contact Center and ask that we mail a form to you.
Signature. You (or your signing authority) must properly complete your request. USCIS will not accept a stamped or
typewritten name in place of any signature on this request. If you are under 14 years of age, your parent or legal guardian
may sign the request on your behalf. A legal guardian may also sign for a mentally incompetent person. If your request is
not signed, or if the signature is not valid, we will reject your request. See 8 CFR 103.2(a)(7)(ii)(A). If USCIS accepts a
request for adjudication and determines that it has a deficient signature, USCIS may deny the request.
Validity of Signatures. USCIS will consider a photocopied, faxed, or scanned copy of an original handwritten signature
as valid for filing purposes. The photocopy, fax, or scan must be of the original document containing the handwritten ink
signature.
Evidence. When you file your request, you must submit all evidence and supporting documents listed in the Specific
Instructions section of these Instructions.
Copies. You should submit legible photocopies of requested documents unless the Instructions specifically instruct you to
submit an original document. USCIS may request an original document at any time during our process. If we request an
original document from you, we will return it to you after USCIS determines it no longer needs the original.
NOTE: If you submit original documents when they are not required or requested, USCIS may destroy them after we
receive them.
Translations. If you submit a document with information in a foreign language, you must also submit a full English
translation. The translator must sign a certification that the English language translation is complete and accurate, and that
they are competent to translate from the foreign language into English. The certification must also include their signature,
printed name, the signature date, and their contact information.
USCIS Contact Center. For additional information on the request and Instructions about where to file, change of
address, and other questions, visit the USCIS Contact Center at www.uscis.gov/contactcenter or call at 800-375-5283
(TTY 800-767-1833). The USCIS Contact Center provides information in English and Spanish.

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Disability Accommodations/Modifications. To request a disability accommodation/modification, follow the instructions
on your appointment notice or at www.uscis.gov/accommodationsinfo.
How To Complete Form I-912
1. Type or print legibly in black ink.
2. If you need extra space to complete any item within this request, use the space provided in Part 10. Additional
Information or attach a separate sheet of paper. Type or print your name and Alien Registration Number (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.

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3. 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.

Specific Instructions

Part 1. Basis for Your Request

Item Number 1. Select a basis for your request. You are not required to complete the entire section of this request.
Rather, select one basis or more for which you may qualify and complete the corresponding section as explained below in
Parts 4., 5., and 6.
Part 2. Information About You (Requestor)

Item Number 2. Full Name. Provide your full name. If you have two last names, include both in the Family Name box
and use a hyphen (-) if appropriate. If you do not have a middle name, type or print “N/A.”
Item Number 3. Other Names Used (if any). Provide all other names you have used, including your maiden name.
Item Number 4. Alien Registration Number (A-Number) (if any). Provide your A-Number. We use your A-Number
to identify your immigration records. It begins with an “A” and can be found on correspondence you have received from
the Department of Homeland Security (DHS) or USCIS. If you do not have an A-Number, type or print “N/A.”
Item Number 5. USCIS Online Account Number. You will only have a USCIS Online Account Number (OAN) if you
previously filed a form that has a receipt number that begins with IOE. If you filed the form online, you can find your
OAN in your account profile. If you mailed us the form, you can find your OAN at the top of the Account Access Notice
we sent you. If you do not have a receipt number that begins with IOE, you do not have an OAN. The OAN is not the
same as an A-Number.
Item Number 6. Date of Birth (mm/dd/yyyy). Provide your date of birth in mm/dd/yyyy format. For example, enter
May 1, 1979, as 05/01/1979.
Item Number 7. U.S. Social Security Number (if any). Provide your U.S. Social Security number. If you do not have a
U.S. Social Security number, type or print “N/A.”
Item Number 8. Marital Status. Indicate your current marital status.

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Part 3. Applications and Petitions for Which You are Requesting a Fee Waiver
Item Number 1. Complete the table for yourself and each person requesting a fee waiver with you. Provide the form
numbers and the total number of applications and petitions for which you and any family members are requesting a fee
waiver.
Part 4. Means-Tested Benefits
Item Number 1. If you, your spouse, your parent (if you are under 21 or disabled), or your child living with you receives
a means-tested benefit, complete the table. You must attach supporting documentation. If you provide sufficient proof
that you or your qualifying family member receive a means-tested benefit, your fee waiver will generally be approved.
A means-tested benefit is a public benefit where a person’s eligibility for the benefit, the amount of the benefit, or both,
is based on the person’s income and resources. USCIS will consider means-tested benefits that are Federally, state, or
locally funded and granted by the benefit agency.

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Examples of means-tested benefit programs are Medicaid, Supplemental Nutrition Assistance Program (known as
“SNAP” and formerly called Food Stamps), Temporary Assistance to Needy Families (TANF), and Supplemental Security
Income (SSI), or other public assistance. Consult with your benefit-granting agency or your legal advisor to determine
whether any Federal, state, or local public benefit that you may receive qualifies as a means-tested benefit.
For the purposes of determining an inability to pay the filing fee of the petition or application, the following are not
considered means-tested benefits: Medicare; unemployment benefits; Social Security retirement benefits; Social Security
Disability Insurance (SSDI); Social Security Retirement, Survivors, and Disability Insurance (RSDI); or student financial
aid.
1. Individual Receipt of a Means-Tested Benefit

A. The individual must demonstrate personal receipt of a means-tested benefit. When a parent is residing with a
child who is receiving public housing or Section 8 benefits, Medicaid, Supplemental Nutrition Assistance Program
(SNAP), Temporary Assistance for Needy Families (TANF), or Supplemental Security Income (SSI), the parent is
also considered to be receiving the means-tested benefit.
B. If a child is the sole applicant, the child may provide an individual means-tested benefit or a custodial parent’s
means-tested benefit, if living in the same household.
C. If multiple children are filing at the same time, each child must have an individual receipt of a means-tested
benefit or be under the parent’s household who is receiving a means-tested benefit. USCIS considers children
living in the same household to be receiving the means-tested benefit if the parent(s) are also living in the same
household.
2. Family Member’s Means-Tested Benefits
A. Your spouse and unmarried children under 21 years of age living with you will normally qualify for a fee waiver
as part of your household if you are receiving means-tested benefits.
B. If your spouse is receiving a means-tested benefit, you will normally qualify for a fee waiver as long as you are
residing with your spouse and are not legally separated.
C. You may use a child’s public housing or Section 8 subsidy, Medicaid, SNAP, TANF, or SSI if the child is living in
the same household.
D. If you are 21 years of age or older, you cannot use a parent’s means-tested benefits (such as SSI), even if the
parent is living with you, as evidence of your eligibility for a fee waiver unless you are disabled and your parent
is you legal guardian or surrogate. However, you may use information about your parent’s means-tested benefits
to support a fee waiver request under Part 6. Financial Hardship if the award letter or benefit approval document
indicates the total household income and you are otherwise eligible under those criteria.

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3. Documentation
A. To qualify for a fee waiver, the evidence that you provide must demonstrate that you are currently receiving the
means-tested benefit. This evidence can be in the form of a letter, notice, or other agency documents that indicate
that the benefit is being received.
B. Documentation must contain:
(1) Your name (or the name of the person receiving the benefit);
(2) The name of the agency granting the public benefit;
(3) The type of benefit; and

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(4) An indication that the benefit is currently being received (for example, a recently dated letter or document
with effective dates, date of renewal or period the approval ends, if available).
C. If the documentation is more than 12 months old and the benefit is still being received, provide additional
evidence that shows the benefit is currently being received.
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines

To qualify for the fee waiver, your adjusted gross household income must be at or below 150 percent of the Federal Poverty
Guidelines, at the time of filing, based on your household size. The Federal Poverty Guidelines are established by the
Secretary of the Department of Health and Human Services annually. To obtain information on the current Federal Poverty
Guidelines, visit our Web site at www.uscis.gov/I-912P and review Form I-912P, Poverty Guidelines for Fee Waiver
Request.
Your Employment Status

Item Number 1. Employment Status. Indicate your current employment status. If you are both employed and a student,
select Other and provide an explanation.
Item Number 2. Indicate if you are currently receiving unemployment benefits. If applicable, provide the date that you
became unemployed and include the total amount of unemployment benefits you have received in Item Number 7.
Information About Your Spouse

Item Number 3. Indicate whether your spouse is living with you. If your spouse lives with you, list your spouse in the
table provided in Item Number 4. If applicable, indicate whether your spouse provides any financial support to your
household. If your spouse provides any financial support to your household, include any contributions that your spouse
provides to your household in Item Number 7.
Your Household Size
Item Number 4. Indicate whether you are providing the primary financial support for your household.
Complete the table with the information requested about the members of your household including their names, dates of
birth, relationship to you, whether the person is married, whether the person is a full-time student, and whether the person
earns income counted towards household income.
If you are applying for any immigration benefits (such as for adjustment of status) based on a pending or approved petition
or application for VAWA benefits or T or U nonimmigrant status and your head of household, the person upon whose tax
return you are listed as a dependent, or one of your household members is or was your abuser or human trafficker, do not
list that person in Item Number 4. or their income in Item Numbers 5. - 9. below.
For the last column (Is any income earned by this person counted towards the household income?), select yes if income is
received consistently or regularly as wages or salary from these household members’ employment or business.

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At the end of the table, provide the total number of household members. Include the following people, who are dependent
on your income, your spouse’s income, or the head of household’s income, as part of your household size:
1. You;
2. The head of your household (if not you). If the child is applying individually, provide the information of the primary
custodial parent;
A. You are the head of household if you filed the most recent Federal tax return for your household (includes filing as
head of household) or earned the majority of the income for your household.
B. If you are not the head of household, the head of household is the person who filed the most recent Federal
tax return on which you are listed as a dependent or the person who provides the majority of your household’s
income. If you already have or are applying for Special Immigrant Juvenile (SIJ) classification, do not include any
foster or group home household members.

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3. Your spouse, if living with you (if you are separated or your spouse is not living with you, do not include your
spouse); or
4. Any family members living in your household who are dependent on your income, your spouse’s income, or the head
of household’s income, including:
A. Your children or legal wards who are unmarried and under 21 years of age, and who live with you;
B. Your children or legal wards who are unmarried, are over 21 years of age but under 24 years of age, are full-time
students, and who live with you when not at school;
C. Your children or legal wards who are unmarried and for whom you are the legal guardian because they are
physically or developmentally disabled or mentally impaired to the extent that they cannot adequately care for
themselves and cannot establish, maintain, or re-establish their own household;
D. Your parents who live with you; and

E. Any other dependents listed on your Federal tax return or your spouse or head of household’s Federal tax returns.
Your Annual Adjusted Household Income

Item Number 5. Your Annual Income. Provide information on your annual income. If you filed a Federal tax return,
enter the amount from Line 37 (adjusted gross income) on Internal Revenue Service (IRS) Form 1040, U.S. Individual
Income Tax Return. If you have not filed a Federal tax return, take your total household wage income (before any
deductions) for the previous 12-month period and enter that amount as your household’s annual income. If you have
not filed a Federal income tax return but you have an IRS Form W-2, Wage and Tax Statement, that covers the previous
12-month period, take your total wage income, deduct Federal, state, and local income taxes withheld, and enter that
amount as your household’s annual wage income.
Documentation. To document your annual income, provide copies of the following:
1. A copy of your most recent Federal tax return, if available;
2. If you did not file a Federal tax return, or if your Federal tax return does not properly reflect your current income,
submit copies of consecutive pay statements (stubs) for a minimum of the past month, recent Form W-2, Form SSA1099, or statements from your employers on business stationery showing salary or wages paid;
3. If you are a student and not living with your parents or are not claimed as a dependent on your parents’ Federal
tax return, do not include your parents’ incomes. You should only provide proof of your income or documentation
that shows you are not required to file a Federal or state tax return, such as proof that you are a full-time student as
supporting documentation;

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4. If you are recently unemployed, and your annual income on your Federal tax return or other proof of income is above
150 percent of the Federal Poverty Guidelines, describe your particular situation that you believe qualifies you for a
fee waiver in Part 5., Item Number 9. Provide information regarding any unemployment benefits you are currently
receiving;
5. If you do not have any income, financial support, or cannot provide evidence of income, describe your particular
situation that you believe qualifies you for a fee waiver in Part 5., Item Number 9. If available, you may submit
affidavits from, for example, religious institutions, non-profits, community-based organizations, or similarly
recognized organizations, indicating that you are currently receiving some benefit or support from the organization
verifying (or attesting to) your situation.
Item Number 6. Annual Adjusted Income of All Household Members. Provide the annual income from all family
members counted as part of your household.

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1. If a person lives with you, but does not contribute financial support to your household, then you should not include
this person’s income when calculating your household income.
2. If you are separated or still married, but do not live with your spouse, do not include your spouse’s income. However,
you must include any financial support your spouse provides to your household in Item Number 7.
3. If you are applying for any immigration benefits (such as for adjustment of status) based on the Violence Against
Women Act (VAWA), or T or U nonimmigrant status under the Victims of Violence and Trafficking Protection
Reauthorization Act, do not provide your spouse’s income. You do not need to include as a household member or
provide income for:
•

Any person in the household who is or was the requestor’s abuser, human trafficker, or perpetrator; or

•

A person who is or was a member of the abuser, human trafficker, or perpetrator’s household.

4. If you are a full-time student, over 21 years of age but under 24 years of age, are unmarried, and are living with your
parents, or you are claimed as a dependent on your parents’ Federal tax return, include your parents’ income. You
must provide a copy of both parents’ Federal tax returns and your own Federal tax return, or provide proof of income
as supporting documentation.
5. If members of your household are recently unemployed, and your annual household income on your Federal tax return
or other proof of income is above 150 percent of the Federal Poverty Guidelines, describe your particular situation
that you believe qualifies you for a fee waiver in Part 5., Item Number 9.
6. If members of your household are recently unemployed, describe the particular situation in Part 5., Item Number 9.
Documentation. To document your household members’ incomes, provide the following:
1. A copy of each household member’s most recent Federal tax return, if available;
2. If the household member did not file a Federal tax return, or if the tax return does not properly reflect their current
income, submit copies of consecutive pay statements (stubs) for a minimum of the past month, a recent Form W-2,
Form SSA-1099, or employer statements on business stationery showing salary or wages paid; or
3. If you do not have any income or cannot provide evidence of income for your household, describe your particular
situation in Part 5., Item Number 9. If applicable, you may submit affidavits from religious institutions, non-profits,
or community-based organizations verifying that you are currently receiving some benefit or support from them.
In addition, if no unemployment compensation is being received, you may submit a letter of termination from the
employer.
Item Number 7. Total Additional Income or Financial Support. Provide additional income or financial support from
a source outside your household. Type or print “0” if you have no additional income. You must include any consistent or
regular financial support or additional income contributed to your household by any person living with you or not living
with you, even if it is not part of the household for tax purposes.

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Select any type of additional income you are receiving including any amount of money that you receive annually that is
not included in Item Number 5. or 6.
Documentation. You must document additional financial assistance as income. Include the following information:
1. Documentation such as parental support; alimony; child support; educational stipends; pensions; Social Security;
royalties, pensions, veterans benefits; unemployment benefits; and consistent or regular financial support from adult
children, parents, dependents, or other people living in your household.
2. A court order of any child support or documentation that indicates the actual amount of child support amount being
received (for example, bank statements or IRS Form W-2), or documentation from an agency providing the other
income or financial assistance.

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3. A copy of your most recent Federal tax return, if available. If you are receiving unemployment benefits, the tax
document, IRS Form 1099-MISC, is not enough to establish total income. Provide information regarding any
unemployment benefits you are currently receiving in Part 5., Item Numnber 9.
Item Number 8. Total Household Adjusted Gross Income. Provide the total household income. Add the amounts from
Item Numbers 5., 6., and 7. USCIS will compare this amount to the Federal Poverty Guidelines.
If you do not have any income, financial support, or cannot provide evidence of income, describe your particular situation
that you believe qualifies you for a fee waiver in Part 5., Item Number 9. If applicable, you may submit affidavits from
religious institutions, non-profits, or community-based organizations verifying that you are currently receiving some
benefit or support from them.
Item Number 9. Indicate whether any information (including marital status, income, and list of dependents) in
your Federal tax return is different from what you indicate in Form I-912. Provide the reasons for any changes in
circumstances and any differences between the tax returns and information in your Form I-912. If you need to explain
anything else about your circumstances that affect the income determination, use the space provided in Part 10.
Additional Information.
Part 6. Financial Hardship

Item Number 1. Provide details about your financial hardship. This may include, but is not limited to:
•

A medical emergency or illness, including mental or physical illness, affecting the noncitizen or the noncitizen’s
dependents;

•

Unemployment;

•

Significant loss of work hours and wages (change in employment status), including that which resulted from a medical
emergency or illness;

•

Eviction;

•

Homelessness;

•

Military deployment of spouse or parent;

•

Natural disaster;

•

Loss of home (destruction such as fire, water, or collapse);

•

Inability to pay basic utilities and rent or mortgage (payments and bills for each month are more than the monthly
wages);

•

Substantial financial losses to small business that affects personal income;

•

Victimization;

•

Divorce or death of a spouse that affects overall income; or

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•

Situations that could not normally be expected in the regular course of life events.

You may also complete this section if your income is above 150 percent of the Federal Poverty Guidelines as defined in
Part 5. and you believe you have special circumstances that warrant a fee waiver.
Documentation. Provide documentation related to your financial hardship including information on income and the
following based on the type of circumstance:
•

Medical bills for yourself, spouse, child or parent

•

Letter of termination or receipt of unemployment benefits

•

Pay statements indicating change in income

•

Letter of eviction

•

Letter from homeless shelter services or statement of lack of income

•

Deployment orders

•

Documentary assistance from FEMA or other assistance, insurance documents

•

Documentation of insurance documentation or assistance from FEMA or other program

•

Documentation of bills for utilities and mortgages and income

•

Documentation of substantial financial losses

•

Victimization; - provide receipt notice for filing under VAWA, T, or U category

•

Divorce decree or death certificate and documentation of income loss

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Item Number 2. List the types of assets you have, the dollar value of those assets, and the total dollar value of your
assets. Include the following assets:
1. Cash, checking and savings accounts, annuities, stocks, and bonds. These are assets that easily covert into cash; and
2. Other property or assets that you can easily convert into cash without incurring a hardship.

Do not include your retirement account (401K plans or Individual Retirement Accounts (IRA)) as assets unless this is your
sole means of income.
Documentation. You must document your income and provide a complete list, description, and an estimate of the value
of your assets that you can easily convert into cash and any liabilities.
Item Number 3. Total Monthly Expenses and Liabilities. Provide your average monthly costs for all applicable
categories provided.
Documentation. Provide evidence, where possible, such as copies of monthly bills and payments, and documentation for
monthly expenses and any extenuating circumstances, such as medical bills. If you cannot provide evidence of income,
you may submit affidavits from religious institutions, non-profits, or community-based organizations verifying that you
are currently receiving some benefit or support from them.
Part 7. Requestor’s Statement, Contact Information, Certification, and Signature
Item Numbers 1. - 6. Select the appropriate box to indicate whether you read this request yourself or whether you had
an interpreter assist you. If someone assisted you in completing the request, select the box indicating that you used a
preparer. Further, you must sign and date your request and provide your daytime telephone number, mobile telephone
number (if any), and email address (if any). Every request MUST contain the signature of the requestor (or parent or legal
guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.

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Part 8. Interpreter’s Contact Information, Certification, and Signature
Item Numbers 1. - 7. If you used anyone as an interpreter to read the Instructions and questions on this request to you in
a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and address
of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone number
(if any), and his or her email address (if any). The interpreter must sign and date the request.
Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other Than the
Requestor
Item Numbers 1. – 8. This section must contain the signature of the person who completed your request, if other than
you, the requestor. If the same individual acted as your interpreter and your preparer, that person should complete both
Part 8. and Part 9. If the person who completed this request is associated with a business or organization, that person
should complete the business or organization name and address information. Anyone who helped you complete this
request MUST sign and date the request. A stamped or typewritten name in place of a signature is not acceptable. If the
person who helped you prepare your request is an attorney or accredited representative, he or she may be obliged to also
submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or Form G-28I,
Notice of Entry of Appearance as Attorney In Matters Outside the Geographic Confines of the United States, along with
your request.

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Part 10. Additional Information

Item Numbers 1. - 6. If you need extra space to provide any additional information within this request, use the space
provided in Part 10. Additional Information. If you need more space than what is provided in Part 10., you may make
copies of Part 10. to complete and file with your 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.
We recommend that you print or save a copy of your completed request for your records.

Where To File?

Mail your Form I-912, along with the completed USCIS applications or petitions, and all supporting documentation
according to the Where to File section in the Instructions of the application or petitions for which you are requesting a fee
waiver.

Address Change
If you are not a U.S. citizen, you must notify USCIS of your new address within 10 days of moving from your previous
residence. For information on changing your address, go to our website at www.uscis.gov/addresschange, or call the
USCIS Contact Center.
NOTE: Do not submit a change of address request to the USCIS Lockbox.

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Processing Information
Decision. The decision on Form I-912 involves a determination of whether you have established eligibility for the fee
waiver. USCIS will notify you of the decision in writing. If USCIS denies your fee waiver request, the notice will include
information on resubmitting your application or petition. For certain immigration benefits, you may have only a limited
period of time in which to resubmit your application or petition with the proper filing fee. Please review the Instructions
for the application or petition for which you want USCIS to consider a fee waiver to determine when to refile.

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USCIS Forms and Information

To ensure you are using the latest version of this request, visit www.uscis.gov.

Penalties

If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-912, we 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.

DHS Privacy Notice

AUTHORITIES: The information requested on this request, and the associated evidence, is collected under the
Immigration and Nationality Act sections 286 and 8 CFR 103.7(c).
PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have
established eligibility for a fee waiver for the associated immigration benefit in which you are filing. The Department of
Homeland Security (DHS) uses the information you provide to grant or deny the immigration benefit you are seeking
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and
any requested evidence, may delay a final decision in your case or result in denial of your request and rejection of your
application or petition based on non-payment of the filing fee.
ROUTINE USES: DHS may share the information you provide on this request with other Federal, state, local, and
foreign government agencies and authorized organizations. DHS follows approved routine uses described in the
associated published system of records notices [DHS-USCIS-007- Benefits Information System and DHS-USCIS-001Alien File, Index, and National File Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS
may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.

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Paperwork Reduction Act
USCIS may not conduct or sponsor an information collection, and you are not required to respond to a collection
of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The
public reporting burden for this collection of information is estimated at 1.095 hours per response, including the time
for reviewing instructions, gathering the required documentation and information, completing the request, preparing
statements, attaching necessary documentation, and submitting the request. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S.
Citizenship and Immigration Services, Office of Policy and Strategy, Regulatory Coordination Division, 5900 Capitol
Gateway Drive, Mail Stop #2140, Camp Springs, MD 20588-0009; OMB No. 1615-0116. Do not mail your completed
Form I-912 to this address. We recommend that you print or save a copy of your completed request to review in
the future and for your records.

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