Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 5
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11Part 6. Financial Hardship (continued)
3.
Total Monthly Expenses and Liabilities
$
Provide the total monthly amount of your expenses and liabilities. You must add all of the expense and liability amounts and type
or print the total amount in the space provided. Type or print "0" in the total box if there are none. Select the types of expenses or
liabilities you have each month and provide evidence of monthly payments, where possible.
Rent and/or Mortgage
Loans and/or Credit Cards
Other
Food
Car Payment
Utilities
Commuting Costs
Child and/or Elder Care
Medical Expenses
Insurance
School Expenses
Part 7. Requestor's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.
Each person applying for a fee waiver request must complete, sign, and date Form I-912 and provide the required documentation.
This includes family members identified in Part 3. Signature fields for family members are at the end of this part. If an individual is
under 14 years of age, a parent or legal guardian may sign the request on their behalf. USCIS rejects any Form I-912 that is not signed
by all individuals requesting a fee waiver and may deny a request that does not provide required documentation.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
Requestor's Statement Regarding the Interpreter
A.
I can read and understand English, and I have read and understand every question and instruction on this request and my
answer to every question.
B.
The interpreter named in Part 9. read to me every question and instruction on this request and my answer to every
question in
, a language in which I am fluent,
and I understood everything.
2.
Requestor's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 10.,
,
prepared this request for me based only upon information I provided or authorized.
Requestor's Contact Information
3.
Requestor's Daytime Telephone Number
4.
Requestor's Mobile Telephone Number (if any)
5.
Requestor's Email Address (if any)
Requestor's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this request, in supporting documents, and in my USCIS records to other entities
and persons where necessary for the administration and enforcement of U.S. immigration laws.
I certify, under penalty of perjury, that I provided or authorized all of the information in my request, I understand all of the
information contained in, and submitted with, my request, and that all of this information is complete, true, and correct.
Form I-912 04/25/16 Y
Page 5 of 11
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