Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 11

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Part 11. Additional Information
If you need extra space to provide any additional information within this request, use the space below. If you need more space than
what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper. Include
your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which
your answer refers.
1.
Family Name (Last Name)
Given Name (First Name)
Middle Name
A-Number (if any) ►
A-
2.
3.
A.
Page Number
B.
Part Number
C.
Item Number
D.
4.
A.
Page Number
B.
Part Number
C.
Item Number
D.
5.
A.
Page Number
B.
Part Number
C.
Item Number
D.
6.
A.
Page Number
B.
Part Number
C.
Item Number
D.
Form I-912 04/25/16 Y
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