Fillable Form I-912: Request for Fee Waiver (USCIS)

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Form I-912: Request for Fee Waiver (USCIS)

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The Form I-912: Request for Fee Waiver (USCIS) form is 9 pages long and contains:

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-912 Edition 10/02/20 Page 1 of 9
PREVIEW
Request for Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
For
USCIS
Use
Only
USCIS
Form I-912
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 Rejected
Date:______________
Fee Waiver Approved
Date:______________
Fee Waiver Rejected
Date:______________
Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
My annual household income is at or below 125 percent of the Federal Poverty Guidelines and I am applying for, have
status as, or have been approved as one of the following:
A battered spouse or child of a lawful permanent resident or U.S. citizen or derivative of such individual under INA
240A(b)(2)
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 7. Additional Information.
Complete and submit as many copies of Part 7., as necessary, with your request.
Select a basis for which you may qualify and provide supporting documentation for any basis you select.
A.
A T nonimmigrant
A U nonimmigrant
A VAWA self -petitioner or his or her derivative
Temporary Protected Status (TPS)
What is your current immigrant or nonimmigrant status?
A Special Immigrant Juvenile (SIJ), and I am currently placed in out-of-home care under the supervision of a
juvenile court or a state child welfare agency
Applicant as an Afghan or Iraqi Translator or Interpreter, Iraqi National employed by or on behalf of the U.S.
Government, or Afghan National employed by or on behalf of the U.S. government or employed by the International
Security Assistance Forces.
►
Provide the Receipt Number for the category you indicated in Item Number 1.A.
B.
2.
I am impacted by an emergent circumstance or major natural disaster declaration posted to www.uscis.gov providing relief
from USCIS filing fees and my documented annual household income is at or below 125 percent of the Federal Poverty
Guidelines (FPG), and I am not seeking an immigration benefit for which I would be subject to the public charge ground
of inadmissibility, the affidavit of support requirement under INA 212(a)(4)(C) or (D), and I am not already a sponsored
immigrant as defined by 8 CFR 213a.1.
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.
Form I-912 Edition 10/02/20 Page 2 of 9
PREVIEW
Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions) (continued)
For what application(s) or petition(s) are you applying for a fee waiver?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 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 3. Alien Registration Number (A-Number)
A-
► ►
Date of Birth (mm/dd/yyyy)5. 6. U.S. Social Security Number
►
Marital Status7.
Marriage Annulled SeparatedSingle, Never Married Married Divorced Widowed
Other (Explain)
Part 3. Household Gross Income
Your Employment Status
Employment Status1.
Other (Explain)
Retired
Employed (full-time, part-time,
seasonal, self-employed)
Unemployed or
Not Employed
For information regarding required documentation, see the instructions.
If you are an SIJ placed in out-of-home care under the supervision of a juvenile court or state child welfare agency, you do not need to
complete Part 3.
Form I-912 Edition 10/02/20 Page 3 of 9
PREVIEW
2. If you are currently unemployed, are you currently receiving unemployment benefits? Yes No
Date you became unemployed (mm/dd/yyyy)
A.
Part 3. Household Gross Income (continued)
Information About Your Spouse
3. If you are married (including separated, but not divorced), does your spouse live in your household?
If you answered “No” to Item Number 3., does your spouse provide any financial support to your household?A.
Yes (add your spouse to the table below and provide
his or her income in Item Number 7. below)
No N/A - not married
No Yes (provide financial support income in
Item Number 8. below)
4. Are you the person providing the primary financial support (head of household) 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 and also provide
your gross income in Item Number 6. 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 Gross 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)
Your Annual Gross Household Income
5.
A.
Did you file a federal tax return for the last year?
No
Yes
Did any of your household members file a tax return for the last year?
If you answered “No” to Item A., provide an answer to Item B. and C.
If no, which household member(s) did not file a tax return?
Yes
No
If you answered “No” to Item Number 5., provide an answer to Item C.
B.
Form I-912 Edition 10/02/20 Page 4 of 9
PREVIEW
If you received additional income on a continuing basis (e.g., monthly or annually) 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.
If you or your household member(s) did not file a tax return, select the reason for not filing and provide an explanation.
I/we filed for an extension.
I/we are not going to file.
I/we plan to file the tax return before the due date this year.
I/we are not required to file a tax return for the current or previous year.
Explanation:
Part 3. Household Gross Income (continued)
C.
Provide information about your gross income and the income of all family members counted as part of your household. You must list
all amounts in U.S. dollars.
6. Your Annual Gross Income
7.
Annual Gross Income of All Family Members Counted as Part of Your Household (Do not include the
amount provided in Item Number 6.)
$
$
8.
Total Additional Income or Financial Support (Do not include the amount provided in Item Number
6. or 7.)
$
Veteran's Benefit
Social Security Benefit
Unemployment Benefit
Pension
Royalties
Educational Stipend
Child Support
Spousal Support (Alimony)
Annual Amount (in dollars)Type of Income
Parental Support Yes No
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
Financial Support from Adult
Child(ren), Dependent, Other Person
Living in the Household
NoYes
NoYesOther: (Explanation Below)
Total Additional Income and Financial Support
Form I-912 Edition 10/02/20 Page 5 of 9
PREVIEW
9. Total Annual Gross Household Income (add the amounts from Item Numbers 6., 7., and 8.)
10.
Has any information you reported in the last income tax return changed since the date you filed your
Federal income tax return? (For example, your marital status, income, or number of dependents.)
Yes No
If you answered "Yes" to Item Number 10., 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 U.S. Citizenship and
Immigration Services (USCIS) to consider.
$
Part 3. Household Gross Income (continued)
11.
If you already have or are applying for VAWA benefits or T or U nonimmigrant status, are you unable to
obtain documentation of your income or a household member's income?
Yes No
If you answered “Yes” to Item Number 11., provide an explanation below explaining your inability to obtain the required
documentation. Provide any other available documentation of your and your household's income. 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.
question in , a language in which I am fluent,
At my request, the preparer named in Part 6., ,
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 4. 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.
The interpreter named in Part 5. 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.
Requestor's Daytime Telephone Number3. 4. Requestor's Mobile Telephone Number (if any)
Requestor's Contact Information
Requestor's Email Address (if any)5.
Form I-912 Edition 10/02/20 Page 6 of 9
PREVIEW
Part 4. Requestor's Statement, Contact Information, Certification, and Signature (continued)
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.
Requestor's Signature
Requestor's Signature Date of Signature (mm/dd/yyyy)
7.
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.
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 reject or deny your request.
Interpreter's Daytime Telephone Number 4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
6.
Interpreter's Mailing Address
3.
City or Town
State ZIP Code
Street Number and Name Flr.Ste.Apt.
Postal Code CountryProvince
Number
Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)
1.
Interpreter's Business or Organization Name (if any)
2.
Interpreter's Full Name
Interpreter's Mobile Telephone Number (if any) 5.
Part 5. Interpreter's Contact Information, Certification, and Signature
(USPS ZIP Code Lookup)
Form I-912 Edition 10/02/20 Page 7 of 9
PREVIEW
Part 5. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Certification
I am fluent in English and , which is the same language specified
in Part 4., 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 Requestor'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)
7.
Interpreter's Signature
Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor
Preparer's Family Name (Last Name) Preparer's Given Name (First Name)1.
Preparer's Full Name
Preparer's Business or Organization Name (if any)2.
3.
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 4.
Preparer's Email Address (if any)6.
5. Preparer's Mobile Telephone Number (if any)
Preparer's Contact Information
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.
7.
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.
Form I-912 Edition 10/02/20 Page 8 of 9
PREVIEW
Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor (continued)
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 Requestor'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)8.
Preparer's Signature
Form I-912 Edition 10/02/20 Page 9 of 9
PREVIEW
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. Include
your name and A-Number at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your
answer refers.
A-Number ►
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 (USCIS)

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Completed 24 September 2020

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