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Form I-912, Request for
Fee Waiver
Department of Homeland Security U.S. Citizenship and Immigration Services
OMB No. 1615-0116; Expires 10/31/
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/
Widow(er)
Marriage Annulled Legally Separated Divorced
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
Complete the Table Below (If you need more space, attach a separate sheet of paper)
Yes No
Name of Agency Awarding Benefit
Date Benefit Was Awarded
Are You Receiving This Benefit Now?
Yes No
Yes No
Yes No
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.
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.
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.
Additional Signature Date
Additional Signature Date
Additional Signature Date
Additional Signature Date
Rent Mortgage
Food Utilities Child/Elder care
Medical School
Type of Cost Value (Enter Dollars) Insurance
Loan Payment
Commuting Costs
TOTAL Monthly Costs
Additional Signature Date
