Form I-912, Request for Fee Waiver

Form I-912 Edition 04/01/24 Page 1 of 8

Request for Fee Waiver

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form I-912

OMB No. 1615-0116

Expires: 02/28/2026

For

USCIS

Use

Only

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. - 9.)

My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part

5., and Parts 7. - 9.)

I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 9.)

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 10. Additional Information.

Complete and submit as many copies of Part 10., 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.

Family Name (Last Name) Given Name (First Name)

Middle Name

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 that you are filing for

yourself. If you are the parent or legal guardian filing on behalf of a child or person with a developmental or mental impairment,

provide information about the child or person for whom you are filing this form.

Other Names Used (if any) 3.

Family Name (Last Name) Given Name (First Name) Middle Name

List all other names you have used, including nicknames, aliases, and maiden name.

5. USCIS Online Account Number (if any)4. Alien Registration Number (A-Number) (if any)

A-

► ►

2. What is your current immigrant or nonimmigrant status?

1. Check here if you are a parent or legal guardian filing on behalf of the person seeking the fee waiver.

A.1.

Form I-912 Edition 04/01/24 Page 2 of 8

Marital Status8.

Marriage Annulled Separated

Part 2. Information About You (Requestor) (continued)

Part 3. Applications and Petitions for Which You Are Requesting a Fee Waiver

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-

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 they are 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)

Single, Never Married Married Divorced Widowed

Other (Explain)

If you selected Item Number 1.A. in Part 1., complete this section.

Date of Birth (mm/dd/yyyy)

6. 7. U.S. Social Security Number (if any)

►

Self

Form I-912 Edition 04/01/24 Page 3 of 8

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

If you selected Item Number 1.B. in Part 1., complete this section.

Provide information about your adjusted gross income. See Instructions for more details.

2. If you are currently unemployed, are you currently receiving unemployment benefits?

Yes No

Date you became unemployed (mm/dd/yyyy)

3. What is your total household size

6. Your Annual Adjusted Gross Income

Provide information about your adjusted gross income and the adjusted gross income of all family members counted as part of your

household. You must list all amounts in U.S. dollars.

Your Annual Household Income

What is the total number of household members earning income including yourself 4.

Name of head of household (if not you): 5.

Annual Adjusted Gross Income of All Family Members

Provide the annual adjusted gross income of all family members counted as part of your household.

(Do not include the amount provided in Item Number 6.)

Total Adjusted Gross Household Income (add the amounts from Item Numbers 6. and 7.)

9. Has anything changed since the date you filed your Federal tax returns or is there any difference in your

circumstances from the information on your petition? (For example, your marital status, income, or

number of dependents as related to documents provided.)

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.

Form I-912 Edition 04/01/24 Page 4 of 8

Part 6. Financial Hardship

1. 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. 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. This may include homelessness, major medical debt for yourself or a family

member, and natural disasters declaration posted to

If you selected Item Number 1.C. 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. $

www.uscis.gov.

Form I-912 Edition 04/01/24 Page 5 of 8

question in , a language in which I am fluent,

At my request, the preparer named in Part 9., ,

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

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 person whose information is provided in Part 2. may sign on behalf of the entire household. If the person listed in Part 2. is

under 14 years of age, a parent or legal guardian may sign on their behalf.

The interpreter named in Part 8. read to me every question and instruction on this request and my answer to every

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.

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.

I certify that the information provided by the requestor in Part 7. applies to the household members identified in Part 3.

Requestor's Signature

Requestor's Signature Date of Signature (mm/dd/yyyy)

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 deny your request.

Form I-912 Edition 04/01/24 Page 6 of 8

Interpreter's Daytime Telephone Number 4.

Interpreter's Email Address (if any)

Interpreter's Contact Information

Interpreter's Certification

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)

Interpreter's Signature

Interpreter's Mailing Address

City or Town

State ZIP Code

Street Number and Name Flr.Ste.Apt.

Postal Code CountryProvince

Number

Provide the following information about the interpreter.

Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)

Interpreter's Business or Organization Name (if any)

Interpreter's Full Name

Interpreter's Mobile Telephone Number (if any) 5.

Part 8. Interpreter's Contact Information, Certification, and Signature

(USPS ZIP Code Lookup)

I am fluent in English and , which is the same language specified

Form I-912 Edition 04/01/24 Page 7 of 8

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.

Preparer's Statement

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.

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

Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other

Than the Requestor

Provide the following information about the preparer for (if applicable).

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.

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)8.

Preparer's Signature

Form I-912 Edition 04/01/24 Page 8 of 8

Part 10. 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

Family Name (Last Name) Given Name (First Name) Middle Name

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.