USCIS Form I-912 Request for Fee Waiver

USCIS form I-912 is a U.S. Department of Homeland Security - Citizenship and Immigration Services form also known as the "Request For Fee Waiver". The latest edition of the form was released in March 13, 2018 and is available for digital filing.

Download a fillable PDF version of the USCIS Form I-912 down below or find it on U.S. Department of Homeland Security - Citizenship and Immigration Services Forms website.

Step-by-step Form 912 instructions can be downloaded by clicking this link.

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Request for Fee Waiver
USCIS
Form I-912
Department of Homeland Security
OMB No. 1615-0116
U.S. Citizenship and Immigration Services
Expires: 03/31/2020
Application Receipted At (Select only one box)
For
USCIS Field Office
USCIS Service Center
USCIS
Use
Fee Waiver Approved
Fee Waiver Denied
Fee Waiver Approved
Fee Waiver Denied
Only
Date:______________
Date:______________
Date:______________
Date:______________
START HERE - Type or print in black ink.
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.
Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
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.
1.
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.)
2.
My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part
5., and 7. - 10.)
3.
I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 10.)
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.
1.
Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
Other Names Used (if any)
List all other names you have used, including nicknames, aliases, and maiden name.
Family Name (Last Name)
Given Name (First Name)
Middle Name
3. Alien Registration Number (A-Number) (if any)
4.
USCIS Online Account Number (if any)
A-
5.
Date of Birth (mm/dd/yyyy)
6. U.S. Social Security Number (if any)
Form I-912 03/13/18
Page 1 of 11
Request for Fee Waiver
USCIS
Form I-912
Department of Homeland Security
OMB No. 1615-0116
U.S. Citizenship and Immigration Services
Expires: 03/31/2020
Application Receipted At (Select only one box)
For
USCIS Field Office
USCIS Service Center
USCIS
Use
Fee Waiver Approved
Fee Waiver Denied
Fee Waiver Approved
Fee Waiver Denied
Only
Date:______________
Date:______________
Date:______________
Date:______________
START HERE - Type or print in black ink.
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.
Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the
Form I-912 Instructions)
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.
1.
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.)
2.
My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part
5., and 7. - 10.)
3.
I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 10.)
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.
1.
Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
Other Names Used (if any)
List all other names you have used, including nicknames, aliases, and maiden name.
Family Name (Last Name)
Given Name (First Name)
Middle Name
3. Alien Registration Number (A-Number) (if any)
4.
USCIS Online Account Number (if any)
A-
5.
Date of Birth (mm/dd/yyyy)
6. U.S. Social Security Number (if any)
Form I-912 03/13/18
Page 1 of 11
Part 2. Information About You (Requestor) (continued)
7.
Marital Status
Single, Never Married
Married
Divorced
Widowed
Marriage Annulled
Separated
Other (Explain)
Part 3. Applications and Petitions for Which You Are Requesting a Fee Waiver
1.
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
Forms Being Filed
A-
A-
A-
A-
Total Number of Forms (including self)
Part 4. Means-Tested Benefits
If you selected Item Number 1. in Part 1., complete this section.
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
Relationship
Name of Agency
Type of
Date Benefit
Date Benefit Expires
Receiving the Benefit
to You
Awarding Benefit
Benefit
was Awarded
(or must be renewed)
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines
If you selected Item Number 2. in Part 1., complete this section.
Your Employment Status
1.
Employment Status
Employed (full-time, part-time,
Other (Explain)
Unemployed or
Retired
seasonal, self-employed)
Not Employed
Form I-912 03/13/18
Page 2 of 11
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)
2. If you are currently unemployed, are you currently receiving unemployment benefits?
Yes
No
A.
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
A.
If you answered “No” to Item Number 3., does your spouse provide any financial support to your
Yes
No
household?
Your Household Size
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.
Household Size
Is any income earned by this
Full
Date of
Relationship
Full-Time
Married
person counted towards the
Name
Birth
to You
Student
household income?
Yes
No
Yes
No
Yes
No
Self
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Total Household Size (including self)
Your Annual Household Income
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.
5. Your Annual Income
$
6. Annual Income of All Family Members
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.)
$
$
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
Educational Stipends
Unemployment Benefits
Financial Support From Adult Children,
Dependents, Other People Living in the
Spousal Support (Alimony)
Royalties
Social Security Benefits
Household
Child Support
Pensions
Veteran's Benefits
Other (Explain)
Form I-912 03/13/18
Page 3 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.)
$
9. Has anything changed since the date you filed your Federal tax returns? (For example, your marital status,
Yes
No
income, or number of dependents.)
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
If you selected Item Number 3. in Part 1., complete this section.
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.
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 03/13/18
Page 4 of 11
Part 6. Financial Hardship (continued)
3.
Total Monthly Expenses and Liabilities
$
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
Loans and/or Credit Cards
Other
Food
Car Payment
Utilities
Commuting Costs
Child and/or Elder Care
Medical Expenses
Insurance
School Expenses
Part 7. Requestor's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.
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.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
Requestor's Statement Regarding the Interpreter
A.
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.
B.
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.
2.
Requestor's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 10.,
,
prepared this request for me based only upon information I provided or authorized.
Requestor's Contact Information
3.
Requestor's Daytime Telephone Number
4.
Requestor's Mobile Telephone Number (if any)
5.
Requestor's Email Address (if any)
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.
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 03/13/18
Page 5 of 11

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