Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 4
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11Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)
8. Total Household Income (add the amounts from Item Numbers 5., 6., and 7.)
$
9. Has anything changed since the date you filed your Federal tax returns? (For example, your marital status,
Yes
No
income, or number of dependents.)
If you answered "Yes" to Item Number 9., provide an explanation below. Provide documentation if available. You may also
use this space to provide any additional information about your circumstances that you would like USCIS to consider.
Part 6. Financial Hardship
If you selected Item Number 3. in Part 1., complete this section.
1.
If you or any family members have a situation that has caused you to incur expenses, debts, or loss of income, describe the
situation in the box below. Specify the amounts of the expenses, debts, and income losses in as much detail as possible.
Examples may include medical expenses, job loss, eviction, and homelessness.
2.
If you have cash or assets that you can quickly convert to cash, list those in the table below. For example, bank accounts, stocks,
or bonds. (Do not include retirement accounts.)
Assets
Type of Asset
Value (U.S. Dollars)
Total Value of Assets
Form I-912 04/25/16 Y
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