Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services
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11Request for Fee Waiver
USCIS
Form I-912
Department of Homeland Security
OMB No. 1615-0116
U.S. Citizenship and Immigration Services
Expires: 04/30/2018
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 04/25/16 Y
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