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Fillable Printable Form I-942

Fillable Printable Form I-942

Form I-942

Form I-942

Form I-942 12/23/16 Page 1 of 9
START HERE - Type or print in black ink.
For
USCIS
Use
Only
Request Receipted At (Select onlyone box)
USCIS Field Office USCIS Service Center
Reduced Fee Approved
Date:______________
Reduced Fee Denied
Date:______________
Reduced Fee Approved
Date:______________
Reduced Fee Denied
Date:______________
Request for Reduced Fee
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-942
OMB No.1615-0133
Expires 11/30/2018
Family Name (Last Name)Given Name (First Name)
Middle Name
1.
Full Name
Part 1. Information About You (Requestor)
Provide information about yourself. If you are the legal guardian filing on behalf of a person with a physical disability or
developmental or mental impairment, provide information about the person for whom you are filing this form.
Date of Birth (mm/dd/yyyy)2.3.Alien Registration Number (A-Number)
Marital Status4.
Marriage AnnulledSingle, Never Married MarriedDivorcedWidowed
Other (Explain)
Separated
A-
Part 2. Information About Family Members Filing This Request With You
1.
In the table below, add the family members filing this request with you
Full NameA-Number (if any)Date of Birth Relationship to You
A-
A-
A-
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
Form I-942 12/23/16 Page 2 of 9
Information About Your Spouse
2.If you are married or separated, does your spouse live in your household?YesNo
If you answered “No” to Item Number 2., does your spouse provide any financial support to your
household?
A.YesNo
Part 3. Household Income (continued)
If you answered “Yes” to Item Number 3., type or print your name on the line marked “self” in the table below. If you answered
“No” to Item Number 3., 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.
Household Size
Full
Name
Full-Time
Student
YesNo
YesNo
YesNo
YesNo
Relationship
to You
Date of
Birth
Married
YesNo
YesNo
YesNo
Yes
No
Does Person Earn
Income Counted Toward
Household Income?
YesNo
YesNo
YesNo
YesNo
Self
Total Household Size (including self)
4.Your Annual Income
5.Annual Income of All Household 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 above under Household Size in
Item Number 3. (Do not include the amount provided in Item Number 4.)
6.Total Additional Income or Financial Support
Provide the total annual amount you receive in additional regular income or financial support from a source outside of your
household. (Do not include the amount provided in Item Number 4. or 5.) You must add all of the additional income and
financial support amounts that you regularly receive and put the total amount in the space provided. Type or print "0" in the total
box if there is 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
Other (Explain)
Unemployment
Social Security Benefits
Veteran's Benefits
Financial Support From
Adult Children,
Dependents, Other People
Living in the Household
7.Total Household Income (add the amounts from ItemNumbers4., 5., and 6.)
3.Are you the person providing the primary financial support for your household?YesNo
Your Household Size
Form I-942 12/23/16 Page 3 of 9
8.
Has anything changed since the date you filed your Federal tax returns? (For example, your marital status,
income, or number of dependents.)
YesNo
If you answered "Yes" to ItemNumber8., provide an explanation below. Provide documentation if available.
At my request, the preparer named in Part 7.,
Requestor's Statement Regarding the Preparer2.
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.
NOTE: 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 6. read to me every question and instruction on this request, and my answer to every
B.
, a language in which I am fluent,
and I understood everything.
NOTE: Read the Penalties section of the Form I-942 Instructions before completing this part.
Requestor's Daytime Telephone Number 3.4.Requestor's Mobile Telephone Number (if any)
Requestor's Contact Information
Requestor's Email Address (if any)5.
Requestor's Statement
question in
Part 3. Household Income (continued)
,
prepared this request for me based only upon information I provided or authorized.
Requestor'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.
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.
Each person applying for a reduced fee must complete, sign, and date Form I-942 and provide the required documentation. This
includes family members identified in Part 2., Item Number 1. Signature fields for family members are at the end of this part. A
legal guardian may sign the request on behalf of the applicant. USCIS rejects any Form I-942 that is not signed by all individuals
requesting a reduced fee and may deny a request that does not provide the required documentation. If the information provided by the
requestor in Part 4. is not applicable to a family member identified in Part 2., that individual should complete Part 5.
Form I-942 12/23/16 Page 4 of 9
Part 4. Requestor's Statement, Contact Information, Certification, and Signature (continued)
Requestor's Signature
Requestor's SignatureDate of Signature (mm/dd/yyyy)
6.
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1)I reviewed and provided or authorized all of the information in my request;
2)I understood all of the information contained in, and submitted with, my request; and
3)All of this information was complete, true, and correct at the time of filing.
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.
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 2., Item Number 1. must sign
and date Form I-942.
I certify that the information provided by the requestor in Part 4. applies to me.
Family Member's Name
Family Member's Name
Family Member 1
Family Member 2
7.
8.
Family Member's SignatureDate of Signature (mm/dd/yyyy)
Family Member's SignatureDate of Signature (mm/dd/yyyy)
Family Member's Name
Family Member's Name
Family Member 3
Family Member 4
9.
10.
Family Member's SignatureDate of Signature (mm/dd/yyyy)
Family Member's SignatureDate 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.
Form I-942 12/23/16 Page 5 of 9
who is is not an attorney or accredited representative, preparing this request for me.
I have requested the services of and consented to ,
2.
Family Member's SignatureDate of Signature (mm/dd/yyyy)
6.
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
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.
Family Member's Certification
I certify, under penalty of perjury, that the information in my request and any document submitted with my request were provided by
me and are complete, true, and correct.
NOTE TO ALL FAMILY MEMBERS: If you do not completely fill out this request or fail to submit required documents listed in
these Instructions, USCIS may deny your request.
I can read and understand English, and have read and understand every question, instruction, and answer on this request.A.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
Part 5. Family Member's Statement, Contact Information, Certification, and Signature
1.
The interpreter named in Part 6. has also read to me every question, instruction, and answer on this request in
B.
, a language in which I am fluent. I understand
every question and instruction on this request as translated to me by my interpreter, and have provided complete, true,
and correct responses in the language indicated above.
NOTE: Read the information on penalties in the Penalties section of the Form I-942 Instructions before completing this part.
If the information provided by the requestor in Part 4. is not applicable to a family member identified in Part 2., Item Number 1, (for
example, the family member used an interpreter or speaks a different language) that individual should complete Part 5. USCIS rejects
any Form I-942 that is not signed by all individuals requesting a reduced fee.
Family Member's Statement Regarding the Interpreter for:
Family Member's Statement Regarding the Preparer for:
Form I-942 12/23/16 Page 6 of 9
Part 6. Interpreter's Contact Information, Certification, and Signature
Provide the following information about the interpreter.
Interpreter's Family Name (Last Name)Interpreter's Given Name (First Name)
3.
Interpreter's Business or Organization Name (if any)
4.
Interpreter's Full Name
Interpreter's Mailing Address
5.
City or Town
StateZIP Code
Street Number and NameFlr.Ste.Apt.
Postal CodeCountryProvince
Number
Interpreter's Daytime Telephone Number 6.
Interpreter's Email Address (if any)
Interpreter's Contact Information
8.
Interpreter's Mobile Telephone Number (if any) 7.
Did any person filing this request use an interpreter? Yes, (complete this section). No, (skip to Part 7.)
1.
YesNo
Was the same interpreter used for all individuals requesting a reduced fee (as listed in Part 2.)
2.
YesNo
NOTE for Family Members: If you used a different interpreter than the one used by the requestor, make additional copies of Part 6.,
provide the following information, indicate the family member for whom he or she interpreted, and include the pages with your
completed Form I-942.
Interpreter's Certification
I am fluent in English and
I certify, under penalty of perjury, that:
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.
, which is the same language
Interpreter's Signature
Interpreter's SignatureDate of Signature (mm/dd/yyyy)
9.
Form I-942 12/23/16 Page 7 of 9
Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor
Provide the following information about the preparer.
Preparer's Family Name (Last Name)Preparer's Given Name (First Name)3.
Preparer's Full Name
Preparer's Business or Organization (if any)4.
5.
City or Town
StateZIP Code
Street Number and NameFlr.Ste.Apt.
Postal CodeCountryProvince
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
Did any person prepare this request on your behalf? Yes, (complete this section). No, (skip).
1.
YesNo
Was the same preparer used for all individuals requesting a reduced fee (as listed in Part 2.)
2.
YesNo
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-942.
Preparer's Statement
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.
9.
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-942 12/23/16 Page 8 of 9
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 SignatureDate of Signature (mm/dd/yyyy)8.
Preparer's Signature
Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor (continued)
Form I-942 12/23/16 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.
A-Number (if any)
A-
Page Number
Part NumberItem 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 NumberItem Number
5.B.C.
Page Number
Part NumberItem Number
6.B.C.
A.
A.
A.
A.
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