Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 7
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11Part 8. Family Member's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.
If the information provided by the requestor in Part 7. is not applicable to a family member identified in Part 3., (for example, the
family member used an interpreter or speaks a different language) that individual should complete Part 8. USCIS rejects any Form
I-912 that is not signed by all individuals requesting a fee waiver.
Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
1.
Family Member's Statement Regarding the Interpreter for
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.
Family Member's Statement Regarding the Preparer for
At my request, the preparer named in Part 10.,
,
prepared this request for me based only upon information I provided or authorized.
Family Member's Contact Information
3.
Family Member's Daytime Telephone Number
4.
Family Member's Mobile Telephone Number (if any)
5.
Family Member's Email Address (if any)
Family Member'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.
Family Member's Signature
6.
Family Member's Signature
Date of Signature (mm/dd/yyyy)
NOTE TO ALL FAMILY MEMBERS: If you do not completely fill out this request or fail to submit required documents listed in
the Instructions, USCIS may deny your request.
Form I-912 04/25/16 Y
Page 7 of 11
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