Fillable Printable Form I-912

What is a Form I-912 ?

Form I-912, a form submitted to the United States Citizenship and Immigration Services, is also named Request for Fee Waiver. Form I-912 may be applied by persons who are unable to pay the required filing fees or biometric service fee(s) for any application or petition that is eligible to receive a fee waiver. Form I-912 is to help persons with their fee waiver problems. More information about Form I-912 and its separate instructions is at USCIS. Fill Printable Form I-912 Online, download blank or editable online. Sign, fax and print with Handypdf.com.

Fillable Printable Form I-912

What is a Form I-912 ?

Form I-912

Form I-912 04/25/16 Y 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: 04/30/2018

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.)

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.

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 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 04/25/16 Y 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

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 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 04/25/16 Y 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)

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

Relationship

to You

Date of

Birth

Married

Yes No

Yes

Is any income earned by this

person counted towards the

household income?

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 04/25/16 Y 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.)

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 04/25/16 Y 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

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

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 04/25/16 Y 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)

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 1

Family Member 2

Family Member's Signature Date of Signature (mm/dd/yyyy)

Family Member's Name

Family Member 3

Family Member 4

10.

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 04/25/16 Y 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.

Family Member's Signature Date of Signature (mm/dd/yyyy)

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.

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

The interpreter named in Part 9. read to me every question and instruction on this request and my answer to every

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 04/25/16 Y Page 8 of 11

Interpreter's Daytime Telephone Number 6.

Interpreter's Email Address (if any)

Interpreter's Contact Information

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)

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 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)

Interpreter's Business or Organization Name (if any)

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)

Was the same interpreter used for all individuals requesting a fee waiver (as listed in Part 3.)?

Yes

Form I-912 04/25/16 Y 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.

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 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)

Was the same preparer used for all individuals requesting a fee waiver (as listed in Part 3.)?

Yes

Form I-912 04/25/16 Y 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 04/25/16 Y 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

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.