Official Federal Forms > US Citizenship And Immigration Services
Request For Fee Waiver I-912 - Official Federal Forms
| Request For Fee Waiver Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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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 Before you fill out this form, please read the instructions. FOR USCIS USE ONLY Application Receipted At (check only one box): Section 1. Information About You (Provide information about yourself. If you are applying for a minor child, provide information about the minor child.) Line 1. a. Family Name (Last Name) Line 1. b. Given Name (First Name) Line 1. c. Middle Initial Line 2. Line 3. Line 4. Alien Registration Number Date of Birth Marital Status Never Married Married Line 5. USCIS Field Office Fee Waiver Approved Date:______________ Fee Waiver Denied A(mm/dd/yyyy) Divorced Widow(er) Marriage Annulled Legally Separated Date:______________ USCIS Service Center Fee Waiver Approved Date:______________ Fee Waiver Denied Date:______________ Applications and Petitions (Enter the form number(s) of the application(s) and/or petition(s) for which you are requesting a fee waiver.) Biometrics services fees, where applicable, will be included in the fee waiver request. Section 2. Additional Information for Dependent(s) Line 6. 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? Yes Yes Yes Yes Yes Yes Yes No No No No No No No Date of Birth (mm/dd/yyyy) Relationship to You AAAAAAA- Form I-912 05/10/13 Y Page 1 of 5 Section 3. Basis for Your Request (Check any that apply. For additional information, see the form instructions.) Line 7. a. Line 7. b. Line 7. c. 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.) Section 4. Means-Tested Benefit Line 8. Complete the Table Below (If you need more space, attach a separate sheet of paper.) Name of Person Receiving the Benefit Name of Agency Awarding Benefit Date Benefit Was Awarded Is This Benefit Being Received Now? Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Section 5. Household Income (Provide evidence of monthly income or other support.) Line 9. Other than you, how many others in your household depend on the stated income? (round to the nearest dollar) Line 10. Line 11. 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 (USCIS will compare this amount to Federal Poverty Guidelines) Form I-912 05/10/13 Y Page 2 of 5 Section 6. Financial Hardship Line 12. 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.) If you are currently unemployed, you must complete Lines 13 and 14. Line 13. Line 14. Line 15. Date that you became unemployed (mm/dd/yyyy) Amount of unemployment compensation (monthly) that you are receiving (enter dollars) List your assets and the value of your assets. (If you need more space, attach a separate sheet of paper.) Type of Asset Value (enter dollars) TOTAL Value of Assets Form I-912 05/10/13 Y Page 3 of 5 Section 6. Financial Hardship (Cont'd) Line 16. List your average monthly costs, and provide evidence of monthly payments where possible. (If you need more space, attach a separate sheet of paper.) Type of Cost Rent Mortgage Food Utilities Child/Elder Care Insurance Value (Enter Dollars) Type of Cost Loan Payment Commuting Costs Medical School Other Expenses TOTAL Monthly Costs Value (Enter Dollars) Section 7. Your Signature and Authorization 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. 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.) Line 17. Your Signature Printed Name Line 17.1. Additional Signature Printed Name Date (mm/dd/yyyy) Date (mm/dd/yyyy) Line 17.2. Additional Signature Printed Name Date (mm/dd/yyyy) Line 17.3. Additional Signature Printed Name Date (mm/dd/yyyy) Line 17.4. Additional Signature Printed Name Date (mm/dd/yyyy) Form I-912 05/10/13 Y Page 4 of 5 Section 7. Your Signature and Authorization (continued) Line 17.5. Additional Signature Printed Name Date (mm/dd/yyyy) Line 17.6. Additional Signature Printed Name Date (mm/dd/yyyy) Line 17.7. Additional Signature Printed Name Date (mm/dd/yyyy) Form I-912 05/10/13 Y Page 5 of 5
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