Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 2
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11Part 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 04/25/16 Y
Page 2 of 11
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