U.S. Department of Justice
Executive Office for Immigration Review
Board of Immigration Appeals
OMB# 1125-0003
Fee Waiver Request
If more than one alien is included in your
appeal or motion, only the lead alien need
file this form. This form is to be signed by
the alien, not the alien’s attorney or repre-
sentative of record.
Alien Number (“A” Number):
, declare under penalty of perjury, pursuant to 28 U.S.C. section
1746, that I am the person above and that I am unable to pay the fee. I believe that my appeal/motion is valid, and I
declare that the following information is true and
correct to the best of my knowledge:
Expenses (including dependents)
(business, professional services, self-
employed/independent contracting,
rental payments, etc.)
(phone, electric, gas,
water, etc.)
(real estate, automobile(s),
stocks, bonds, etc.)
(public assistance, alimony,
child support, gift, parent,
spouse, other family members, etc.)
Under the Paperwork Reduction Act, a person is not required to
respond to a collection of information unless it displays a valid OMB
control number. We try to create forms and instructions that are
accurate, can be easily understood, and which impose the least
possible burden on you to provide us with information. The estimated
average time to complete this form is one (1) hour. If you have
comments regarding the accuracy of this estimate, or suggestions for
making this form simpler, you
can write to the Executive Office for
Immigration Review, Office of the General Counsel, 5107 Leesburg
Pike, Suite 2600, Falls Church, Virginia 20530.
_________________________ ________________
Signature of Alien
Date
r Representative (if any):
I hereby attest that I have reviewed the details provided herein and I am
satisfied that this fee waiver request is made in good faith.
__________________________
___________ ________________
ignature of Attorney or Representative Date
_____________________________________
Privacy Act Notice
The information on this form is requested to determine if you have
established eligibility for the fee waiver you are seeking. The legal
right to ask for this information is located at 8 C.F.R. § 1003.8(a)(3).
EOIR may provide this information to other Government agencies.
Failure to provide this information may result in denial of your
request.
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