Fillable form i-912 request for fee waiver 10/15/19

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form i-912 request for fee waiver 10/15/19

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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 10/24/19 Page 1 of 9
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:______________
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 8. Additional Information.
Complete and submit as many copies of Part 8., as necessary, with your request.
Family Name (Last Name) Given Name (First Name)
Middle Name
1.
Full Legal Name
Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
Provide information about yourself if you are requesting a fee waiver for a petition or application you are filing. If you are a parent or
legal guardian filing for 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 request.
Other Names Used (if any) 2.
Family Name (Last Name) Given Name (First Name) Middle Name
Provide all other names you have ever used, including aliases, maiden name, and nicknames.
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)
►
Part 2. Information About You (Requestor)
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.
My household income is at or below 150 percent of the Federal Poverty Guidelines (FPG). (Complete Parts 2. - 3., and
Parts 5. - 7.)
I have a financial hardship. (Complete Part 2., and Parts 4. - 7.)
1.
2.
Marital Status7.
Marriage Annulled SeparatedSingle, Never Married Married Divorced Widowed
Other (Explain)
Form I-912 10/24/19 Page 2 of 9
List and provide the total number of applications and petitions for which you are requesting a fee waiver.8.
NumberForm
Total Number
Part 2. Information About You (Requestor)
Are you applying for or have status or a granted approval as a battered spouse of an A, G, E-3, or H nonimmigrants; a battered
spouse or child of a lawful permanent resident or U.S. citizen under INA section 240A(b)(2); a T nonimmigrant; a person with
Temporary Protected Status; a U nonimmigrant; or a VAWA self -petitioner?
9.
►
Receipt Number (if applicable)A.
Part 3. Household Income
Your Employment Status
Employment Status1.
Other (Explain)
Retired
Employed (full-time, part-time, seasonal, self-employed)
Unemployed or Not Employed
2. If you are currently unemployed, since when have you been unemployed (mm/dd/yyyy)?
No
Yes
If you are currently unemployed, are you currently receiving unemployment benefits?A.
Information About Your Spouse
3. If you are married or separated, 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.
4. Are you the person providing the primary financial support for your household?
Yes
No
Your Household Size
Yes (add your spouse to the table below and provide his or her income in Item Number 9. below)
No
No
Yes (provide financial support income in Item Number 10. below)
Yes
No
Form I-912 10/24/19 Page 3 of 9
Household Size
Full Name
Full-Time
Student
Relationship
to You
Date of
Birth
Married
Yes No
Is any income earned by this
person counted towards the
household income?
Self
Total Household Size (including self)
NoYesNoYes
Part 3. Household Income (continued)
5.
6.
If you or your household member did not file a tax return for the last year, select the reason for not filing and provide an
explanation. See I-912 Instructions for required documentation.
I/we filed for an extension.
I/we are not going to file.
7.
Your Annual Household Income
Did you file a federal tax return for the last year?
No
Yes
Did your household members file tax returns for the last year?
If you answered “No” to Item Number 6., provide an answer to Item Number 7.
If you answered “No” to Item Number 6., 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 Number 7.
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:
If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below. Also provide
income in Item Number 8. 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.
Form I-912 10/24/19 Page 4 of 9
Veteran's Benefits
Social Security Benefits
Unemployment Benefits
Pensions
Royalties
Educational Stipends
Child Support
Spousal Support (Alimony)
Part 3. Household Income (continued)
8.
Your Annual Income
9.
Annual Income of All Family Members Counted as Part of Your Household (Do not include the
amount provided in Item Number 8.)
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.
$
$
10. Total Additional Income or Financial Support (Do not include the amount provided in Item
Numbers 8. or 9.)
If you received additional income on a continuing monthly or annual basis 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.
$
Annual Amount (in dollars)Type of Income
Parental Support Yes No
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
Financial Support from Adult
Children, Dependents, Other People
Living in the Household
NoYes
NoYesOther: (Explanation Below)
Total Additional Income and Financial Support
$
Total Annual Household Income (add the amounts from Item Numbers 8., 9., and 10.)11.
12.
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 12., 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.
Form I-912 10/24/19 Page 5 of 9
Part 4. 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, victimization, and homelessness.
If you selected Item Number 2. 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
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
Total Monthly Expenses and Liabilities 3. $
Form I-912 10/24/19 Page 6 of 9
Requestor's Statement Regarding the Preparer 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 5. Requestor's Statement, Contact Information, Certification, and Signature
A.
Requestor's Statement Regarding the Interpreter
1.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
You must complete, sign, and date Form I-912 and provide the required documentation. 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 and may deny a request
that does not provide required documentation.
The interpreter named in Part 6. 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 section.
At my request, the preparer named in Part 7.,
question in , a language in which I am fluent,
prepared this request for me based only upon information I provided or authorized.
,
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
and all of my records that USCIS may need to determine my eligibility for the immigration benefit that 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 law.
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.
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.
Requestor's Signature
Requestor's Signature Date of Signature (mm/dd/yyyy)
6.
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.
Form I-912 10/24/19 Page 7 of 9
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
Part 6. Interpreter's Contact Information, Certification, and Signature
(USPS ZIP Code Lookup)
Interpreter's Daytime Telephone Number 4.
Interpreter's Email Address (if any)
Interpreter's Contact Information
6.
Interpreter's Certification
I certify, under penalty of perjury, that:
Interpreter's Mobile Telephone Number (if any) 5.
I am fluent in English and
in Part 5., 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.
, which is the same language specified
Interpreter's Signature Date of Signature (mm/dd/yyyy)
7.
Interpreter's Signature
Part 7. 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.
Form I-912 10/24/19 Page 8 of 9
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
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 need 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.
extends
Part 7. 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 10/24/19 Page 9 of 9
Part 8. 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; and sign and date each sheet.
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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