Request for Reduced Fee
USCIS
Form I-942
Department of Homeland Security
OMB No.1615-0133
U.S. Citizenship and Immigration Services
Expires 11/30/2018
Request Receipted At (Select only one box)
For
USCIS Field Office
USCIS Service Center
USCIS
Use
Reduced Fee Approved
Reduced Fee Denied
Reduced Fee Approved
Reduced Fee Denied
Only
Date:______________
Date:______________
Date:______________
Date:______________
►
START HERE - Type or print in black ink.
Part 1. Information About You (Requestor)
Provide information about yourself. If you are the legal guardian filing on behalf of a person with a physical disability or
developmental or mental impairment, provide information about the person for whom you are filing this form.
1. Full Name
Family Name (Last Name)
Given Name (First Name)
Middle Name
2.
Date of Birth (mm/dd/yyyy)
3.
Alien Registration Number (A-Number)
►
A-
4.
Marital Status
Single, Never Married
Married
Divorced
Widowed
Marriage Annulled
Separated
Other (Explain)
Part 2. Information About Family Members Filing This Request With You
1. In the table below, add the family members filing this request with you
Full Name
A-Number (if any)
Date of Birth
Relationship to You
A-
A-
A-
A-
Part 3. Household Income
Your Employment Status
1.
Employment Status
Employed (full-time, part-time,
Other (Explain)
Unemployed or
Retired
seasonal, self-employed)
Not Employed
Form I-942 12/23/16
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