Fillable Printable USCIS Fee Waiver Form I-912
Fillable Printable USCIS Fee Waiver Form I-912
USCIS Fee Waiver Form I-912
Form I-912, Request for
Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0116; Expires 10/31/2012
Before you fill out this form, please read the instructions.
For USCIS Use Only
Family Name (Last Name)
Given Name (First Name)
Middle Initial
Alien Registration Number
A
U.S. Social Security Number
(SSN) (9 numbers only)
Date of Birth
(mm/dd/yyyy)
Marital Status
Never Married
Married
Approved
Signature of
Approving Officer
Denied
Officer's Comments
Line 1. a.
Line 1. b.
Line 1. c.
Line 2.
Line 3.
Line 4.
Line 5.
Line 6.
Section 1. Information About You
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 if Dependent(s) are Included in This Request
Form I-912 11/23/10
Widow(er)
Marriage Annulled
Divorced
Legally Separated
Biometric services fees, where applicable, will be
included in the request.
Line 7. 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)
SSN
(If applicable)
Date of Birth
(mm/dd/yyyy)
Relationship
to You
A-
A-
A-
A-
A-
A-
A-
(A-Number) (numbers only)
Section 4. Means-Tested Benefit
Form I-912 11/23/10 Page 2
Complete the Table Below (If you need more space, attach a separate sheet of paper)
No
Yes
Name of Agency
Awarding Benefit
Date Benefit
Was Awarded
Are You Receiving
This Benefit Now?
No
Yes
No
Yes
No
Yes
Line 9.
Section 5. Household Income
(Provide evidence of monthly income or other support)
Average monthly wage income from household members
Other money received each month (child support, spousal
support, unemployment, etc.)
Total
(round to the nearest dollar)
Line 10.
How many dependents (for tax purposes) live with you?
Line 11.
Line 12.
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)
a. I am receiving a means-tested benefit. (complete Section 4)
b. My household income is at or below 150% of the Federal Poverty Guidelines. (complete Section 5)
c. I have a financial hardship. (complete Section 6)
Line 8. a.
Line 8. b.
Line 8. c.
Form I-912 11/23/10 Page 3
Section 6. Financial Hardship
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). (If you need more space,
attach a separate sheet of paper.)
Line 13.
If unemployed:
Line 14.
Date that you became unemployed
Line 15.
Amount of unemployment compensation (monthly) that you are receiving (enter dollars)
Type of Asset
Value (enter dollars)
TOTAL Value of Assets
Line 16.
List your assets and the value of your assets. (If you need more space, attach a separate sheet of paper.)
Section 6. Financial Hardship (Cont'd)
Type of Cost
Value (Enter Dollars)
List your average monthly cost, provide evidence of monthly payments where possible. (If you need more space,
attach a separate sheet of paper.)
Line 17.
Form I-912 11/23/10 Page 4
Section 7. Your Signature and Authorization
Your Signature
Date
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 18.
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.
Date
Additional Signature
Date
Additional Signature
Date
Additional Signature
Date
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
Date
Additional Signature
