Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 3
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11Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)
2. If you are currently unemployed, are you currently receiving unemployment benefits?
Yes
No
A.
Date you became unemployed
(mm/dd/yyyy)
Information About Your Spouse
3.
If you are married or separated, does your spouse live in your household?
Yes
No
A.
If you answered “No” to Item Number 3., does your spouse provide any financial support to your
Yes
No
household?
Your Household Size
4.
Are you the person providing the primary financial support for your household?
Yes
No
If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below. If you answered
“No” to Item Number 4., type or print your name on the line marked “self” in the table below and add the head of household's
name on the line below yours.
Household Size
Is any income earned by this
Full
Date of
Relationship
Full-Time
Married
person counted towards the
Name
Birth
to You
Student
household income?
Yes
No
Yes
No
Yes
No
Self
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Total Household Size (including self)
Your Annual Household Income
Provide information about your income and the income of all family members counted as part of your household. You must list all
amounts in U.S. dollars.
5. Your Annual Income
$
6. Annual Income of All Family Members
Provide the annual income of all family members counted as part of your household as listed in Item Number 4. (Do not include
the amount provided in Item Number 5.)
$
7.
Total Additional Income or Financial Support
$
Provide the total annual amount you receive in additional income or financial support from a source outside of your household.
(Do not include the amount provided in Item Numbers 5. or 6.) You must add all of the additional income and financial support
amounts and put the total amount in the space provided. Type or print "0" in the total box if there are none. Select the type of
additional income or financial support that you receive and provide documentation.
Parental Support
Educational Stipends
Unemployment Benefits
Financial Support From Adult Children,
Dependents, Other People Living in the
Spousal Support (Alimony)
Royalties
Social Security Benefits
Household
Child Support
Pensions
Veteran's Benefits
Other (Explain)
Form I-912 04/25/16 Y
Page 3 of 11
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