Fillable Printable Fee Waiver Form - USCIS
Fillable Printable Fee Waiver Form - USCIS
Fee Waiver Form - USCIS
Family Name (Last Name)
Given Name (First Name)
Middle Initial
Date of Birth
Marital Status
Line 1. a.
Line 1. b.
Line 1. c.
Line 2.
Line 3.
Line 4.
Line 5.
Line 6.
Section 1. Information About You (Provide information about yourself. If you
are applying for a minor child, provide information about the minor child.)
Applications and Petitions (Enter the form number(s) of the application(s) and/or
petition(s) for which you are requesting a fee waiver.)
Section 2. Additional Information for Dependent(s)
Biometrics services fees, where applicable, will be included in the fee waiver request.
Complete the Table below if applicable. (If you need more space, attach a separate sheet of paper.)
Name (First, MI, Last) A-Number
(If applicable)
Is Individual
Included in Fee
Waiver Request?
Date of Birth
(mm/dd/yyyy)
Relationship to You
A-
A-
A-
A-
A-
A-
A-
Application Receipted At
(check only one box):
FOR USCIS USE ONLY
USCIS Field Office
Fee Waiver Approved
Fee Waiver Denied
USCIS Service Center
Fee Waiver Denied
Fee Waiver Approved
Date:______________
Date:______________
Date:______________
Date:______________
Alien Registration Number
Request for Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-912
OMB No. 1615-0116
Expires 05/31/2015
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A-
►(mm/dd/yyyy)
Never Married
Married
Divorced Marriage Annulled
Legally Separated
Widow(er)
No
Yes
No
Yes
No
Yes
NoYes
No
Yes
No
Yes
No
Yes
Form I-912 05/10/13 Y
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Before you fill out this form, please read the instructions.
Page 1 of 5
Section 4. Means-Tested Benefit
Complete the Table Below (If you need more space, attach a separate sheet of paper.)
Name of Agency
Awarding Benefit
Date Benefit
Was Awarded
Is This Benefit Being
Received Now?
Line 8.
Section 5. Household Income (Provide evidence of monthly income or other support.)
Average monthly wage income from household members
Enter other money received each month that is not included in Line 14.
(This could include spousal support, child support, unemployment, etc.)
TOTAL
(round to the nearest dollar)
Line 9. Other than you, how many others in your household depend on the
stated income?
Line 10.
Line 11.
Name of Person
Receiving the Benefit
(USCIS will compare this amount to Federal Poverty Guidelines)
Section 3. Basis for Your Request (Check any that apply. For additional information, see the form
instructions.)
I am or a relevant member of my household is currently receiving a means-tested benefit. (Complete Sections 4 and 7.)
My household income is at or below 150% of the Federal Poverty Guidelines. (Complete Sections 5 and 7.)
I have a financial hardship. (Complete Sections 5, 6 and 7.)
Line 7. a.
Line 7. b.
Line 7. c.
No
Yes
No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes
No
Yes
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►
►
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Form I-912 05/10/13 Y
Page 2 of 5
Describe your particular situation. Be sure to include how this situation has caused you to incur costs (and what the costs
were) or loss of income that you have experienced (and what that loss was). Complete this section in English; otherwise,
provide an accompanying English translation. (If you need more space, attach a separate sheet of paper.)
Line 12.
If you are currently unemployed, you must complete Lines 13 and 14.
Line 13.
Date that you became unemployed
Line 14. Amount of unemployment compensation (monthly) that you are receiving (enter dollars)
Type of Asset
Value (enter dollars)
TOTAL Value of Assets
Line 15. List your assets and the value of your assets. (If you need more space, attach a separate sheet of paper.)
Section 6. Financial Hardship
►(mm/dd/yyyy)
Form I-912 05/10/13 Y
Page 3 of 5
Type of Cost Value (Enter Dollars)
List your average monthly costs, and provide evidence of monthly payments where possible. (If you need more space,
attach a separate sheet of paper.)
Line 16.
Your Signature
Printed Name
Printed Name
Printed Name
Printed Name
Printed Name
Do not sign your Form I-912 until it is complete and you are ready to file.
I take full responsibility for the accuracy of all the information provided, including all supporting documentation. I authorize the
release of any information, including the release of my Federal tax returns, that USCIS needs to determine my eligibility.
Line 17.
Line 17.1.
Line 17.2.
Line 17.3.
Line 17.4.
Each person applying for a fee waiver request must sign Form I-912. This includes individuals identified in Sections 1 and 2 if
14 years of age or older. (If you need more space, attach a separate sheet of paper.)
Additional Signature
Additional Signature
Additional Signature
Additional Signature
Rent
Mortgage
Food
Utilities
Child/Elder Care
Medical
School
Type of Cost Value (Enter Dollars)
Insurance
Loan Payment
Commuting Costs
TOTAL Monthly Costs
Section 6. Financial Hardship (Cont'd)
Section 7. Your Signature and Authorization
Date (mm/dd/yyyy)
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Date (mm/dd/yyyy)
►
Date (mm/dd/yyyy)
►
Date (mm/dd/yyyy)
►
Date (mm/dd/yyyy)
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Form I-912 05/10/13 Y
Page 4 of 5
Other Expenses
Section 7. Your Signature and Authorization (continued)
Line 17.5.
Line 17.6.
Line 17.7.
Additional Signature
Additional Signature
Additional Signature
Printed Name
Printed Name
Printed Name
Form I-912 05/10/13 Y
Page 5 of 5
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Date (mm/dd/yyyy)
►
Date (mm/dd/yyyy)
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Date (mm/dd/yyyy)
