Fillable Form I-912: Request For Fee Waiver (Visa Pro)

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Form I-912: Request For Fee Waiver (Visa Pro)

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Form I-912 10/15/19 Page 1 of 11
Request for Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
For
USCIS
Use
Only
USCIS
Form I-912
OMB No. 1615-0116
Expires: 10/31/2021
START HERE - Type or print in black ink.►
Application Receipted At (Select only one box)
USCIS Field Office USCIS Service Center
Fee Waiver Approved
Date:______________
Fee Waiver Denied
Date:______________
Fee Waiver Approved
Date:______________
Fee Waiver Denied
Date:______________
Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
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.)
My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part
5., and 7. - 10.)
I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 10.)
1.
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.
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.
2.
3.
Family Name (Last Name) Given Name (First Name)
Middle Name
1.
Full Name
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.
Other Names Used (if any) 2.
Family Name (Last Name) Given Name (First Name) Middle Name
List all other names you have used, including nicknames, aliases, and maiden name.
4. USCIS Online Account Number (if any)3. Alien Registration Number (A-Number) (if any)
A-
► ►
Date of Birth (mm/dd/yyyy)5. 6. U.S. Social Security Number (if any)
►
Form I-912 10/15/19 Page 2 of 11
Marital Status7.
Marriage Annulled Separated
Part 2. Information About You (Requestor) (continued)
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
A-
A-
A-
A-
Forms Being Filed
Total Number of Forms (including self)
Part 4. Means-Tested Benefits
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
Relationship
to You
Name of Agency
Awarding Benefit
Type of
Benefit
Date Benefit
was Awarded
Date Benefit Expires
(or must be renewed)
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines
Your Employment Status
Employment Status1.
Other (Explain)
Retired
Employed (full-time, part-time,
seasonal, self-employed)
Unemployed or
Not Employed
Single, Never Married Married Divorced Widowed
Other (Explain)
If you selected Item Number 1. in Part 1., complete this section.
If you selected Item Number 2. in Part 1., complete this section.
Form I-912 10/15/19 Page 3 of 11
2. If you are currently unemployed, are you currently receiving unemployment benefits? Yes No
Date you became unemployed
(mm/dd/yyyy)
A.
Information About Your Spouse
3. If you are married or separated, does your spouse live in your household? Yes No
If you answered “No” to Item Number 3., does your spouse provide any financial support to your
household?
A. Yes No
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.
Your Household Size
Household Size
Full
Name
Full-Time
Student
Yes No
Yes No
Yes No
Yes No
Relationship
to You
Date of
Birth
Married
Yes No
Yes No
Yes No
Yes
No
Is any income earned by this
person counted towards the
household income?
Yes No
Yes No
Yes No
Yes No
Self
Total Household Size (including self)
5. Your Annual Income
6. Annual Income of All Family Members
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.
Your Annual Household Income
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.)
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)
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
Spousal Support (Alimony)
Child Support
Educational Stipends
Royalties
Pensions
Unemployment Benefits
Social Security Benefits
Veteran's Benefits
Financial Support From Adult Children,
Dependents, Other People Living in the
Household
Other (Explain)
$
$
$
Form I-912 10/15/19 Page 4 of 11
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)
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.)
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.
Part 6. Financial Hardship
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.
If you selected Item Number 3. in Part 1., complete this section.
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.)
Assets
Type of Asset Value (U.S. Dollars)
Total Value of Assets
$
Form I-912 10/15/19 Page 5 of 11
question in , a language in which I am fluent,
Part 6. Financial Hardship (continued)
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
Food
Utilities
Child and/or Elder Care
Insurance
Loans and/or Credit Cards
Car Payment
Commuting Costs
Medical Expenses
School Expenses
Other
At my request, the preparer named in Part 10., ,
prepared this request for me based only upon information I provided or authorized.
Requestor's Statement Regarding the Preparer (if applicable)2.
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.
Part 7. Requestor's Statement, Contact Information, Certification, and Signature
A.
Requestor's Statement Regarding the Interpreter1.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
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.
The interpreter named in Part 9. read to me every question and instruction on this request and my answer to every
B.
and I understood everything.
NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.
Total Monthly Expenses and Liabilities 3.
Requestor's Daytime Telephone Number3. 4. Requestor's Mobile Telephone Number (if any)
Requestor's Contact Information
Requestor's Email Address (if any)5.
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.
Requestor's Certification
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.
$
Form I-912 10/15/19 Page 6 of 11
Part 7. Requestor's Statement, Contact Information, Certification, and Signature (continued)
Requestor's Signature
Requestor's Signature Date of Signature (mm/dd/yyyy)
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.
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 Numbers 7. - 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.
Family Member's Name
Family Member's Name
Family Member 1
Family Member 2
7.
8.
Family Member's Signature Date of Signature (mm/dd/yyyy)
Family Member's Signature Date of Signature (mm/dd/yyyy)
Family Member's Name
Family Member's Name
Family Member 3
Family Member 4
9.
10.
Family Member's Signature Date of Signature (mm/dd/yyyy)
Family Member'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 Member's Name
Family Member 511.
Family Member's Signature Date of Signature (mm/dd/yyyy)
Form I-912 10/15/19 Page 7 of 11
At my request, the preparer named in Part 10., ,
prepared this request for me based only upon information I provided or authorized.
2.
Family Member's Signature Date of Signature (mm/dd/yyyy)
6.
Family Member's Signature
Family Member's Email Address (if any)5.
Family Member's Daytime Telephone Number 3. 4.
Family Member's Mobile Telephone Number (if any)
Family Member's Contact Information
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.
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.
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.
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.
A.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
Part 8. Family Member's Statement, Contact Information, Certification, and Signature
1.
The interpreter named in Part 9. read to me every question and instruction on this request and my answer to every
B.
question in , a language in which I am fluent, and
I understood everything.
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.
Family Member's Statement Regarding the Interpreter for
Family Member's Statement Regarding the Preparer for
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.
Form I-912 10/15/19 Page 8 of 11
Interpreter's Daytime Telephone Number 6.
Interpreter's Email Address (if any)
Interpreter's Contact Information
8.
Interpreter's Certification
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.
I certify, under penalty of perjury, that:
Interpreter's Signature Date of Signature (mm/dd/yyyy)
9.
Interpreter's Signature
Interpreter's Mailing Address
5.
City or Town
State ZIP Code
Street Number and Name Flr.Ste.Apt.
Postal Code CountryProvince
Number
Provide the following information about the interpreter for
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.
Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)
3.
Interpreter's Business or Organization Name (if any)
4.
Interpreter's Full Name
Interpreter's Mobile Telephone Number (if any) 7.
Part 9. Interpreter's Contact Information, Certification, and Signature
Did any person filing this request use an interpreter?
No (skip to Part 10.)Yes, (complete this section)
1.
Was the same interpreter used for all individuals requesting a fee waiver (as listed in Part 3.)?
No
Yes
2.
(USPS ZIP Code Lookup)
Form I-912 10/15/19 Page 9 of 11
extends does not extend beyond the preparation of this request.
I am an attorney or accredited representative and my representation of the requestor in this case
I am not an attorney or accredited representative but have prepared this request on behalf of the
requestor and with the requestor's consent.
9.
Preparer's Statement
B.
A.
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.
5.
City or Town
State ZIP Code
Street Number and Name Flr.Ste.Apt.
Postal Code CountryProvince
Preparer's Mailing Address
Number
Preparer's Daytime Telephone Number 6.
Preparer's Email Address (if any)8.
7. Preparer's Mobile Telephone Number (if any)
Preparer's Contact Information
Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor
Provide the following information about the preparer for
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.
Preparer's Family Name (Last Name) Preparer's Given Name (First Name)3.
Preparer's Full Name
Preparer's Business or Organization Name (if any)4.
Did any person prepare this request on your behalf?
No, skipYes, (complete this section)
1.
Was the same preparer used for all individuals requesting a fee waiver (as listed in Part 3.)?
No
Yes
2.
Form I-912 10/15/19 Page 10 of 11
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 Date of Signature (mm/dd/yyyy)10.
Preparer's Signature
Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor (continued)
Form I-912 10/15/19 Page 11 of 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.
A-Number (if any) ►
A-
Page Number
Part Number Item Number
D.
Family Name (Last Name) Given Name (First Name) Middle Name
1.
2.
3.
D.
D.
D.
B. C.
Page Number
Part Number
Item Number4. B. C.
Page Number
Part Number Item Number
5. B. C.
Page Number
Part Number Item Number
6. B. C.
A.
A.
A.
A.
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Form I-912: Request For Fee Waiver (Visa Pro)

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Completed 29 July 2020

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