Form I-912 - Request For Fee Waiver - U.s. Citizenship And Immigration Services Page 9
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11Part 10. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other
Than the Requestor
1.
Did any person prepare this request on your behalf?
Yes, (complete this section)
No, skip
2.
Was the same preparer used for all individuals requesting a fee waiver (as listed in Part 3.)?
Yes
No
NOTE for Family Members: If you used a different preparer than the one used by the requestor, provide the following information,
and include the pages with your completed Form I-912.
Provide the following information about the preparer for
Preparer's Full Name
3.
Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
4.
Preparer's Business or Organization Name (if any)
Preparer's Mailing Address
5.
Street Number and Name
Apt.
Ste.
Flr.
Number
City or Town
State
ZIP Code
Province
Postal Code
Country
Preparer's Contact Information
6.
Preparer's Daytime Telephone Number
7.
Preparer's Mobile Telephone Number (if any)
8.
Preparer's Email Address (if any)
Preparer's Statement
9.
A.
I am not an attorney or accredited representative but have prepared this request on behalf of the
requestor and with the requestor's consent.
B.
I am an attorney or accredited representative and my representation of the requestor in this case
extends
does not extend beyond the preparation of this request.
NOTE: If you are an attorney or accredited representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative,
or G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical
Confines of the United States, with this request.
Form I-912 04/25/16 Y
Page 9 of 11
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