Form I 912 Waiver – Fill Out and Use This PDF

Select at least one basis or more for which you may qualify and provide supporting documentation for any basis you select. You only need to qualify and provide documentation for one basis for U.S. Citizenship and Immigration Services (USCIS) to grant your fee waiver. If you choose, you may select more than one basis. You must provide supporting documentation for each basis you want considered.

I am, my spouse is, or the head of household living in my household is currently receiving a means-tested benefit. (Complete Parts 2. - 4. and Parts 7. - 9.)

“My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part 5., and Parts 7. - 9.)”

I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 9.)

What is your current immigrant or nonimmigrant status?

Provide information about yourself if you are the person requesting a fee waiver for a petition or application that you are filing for yourself. If you are the parent or legal guardian filing on behalf of a child or person with a developmental or mental impairment, provide information about the child or person for whom you are filing this form.

Check here if you are a parent or legal guardian filing on behalf of the person seeking the fee waiver.

List all other names you have used, including nicknames, aliases, and maiden name.

USCIS Online Account Number (if any) Alien Registration Number (A-Number) (if any)

Date of Birth (mm/dd/yyyy) U.S. Social Security Number (if any)

Marital Status: Single, Never Married, Married, Divorced, Widowed, Marriage Annulled, Separated, Other (Explain)

“In the table below, add the form numbers of the applications and petitions for which you are requesting a fee waiver.” Total Number of Forms (including self)

If you selected Item Number 1.A. in Part 1., complete this section.

“If you, your spouse, or the head of household (including parent if the child is under 21 years of age) living with you is receiving any means-tested benefits, list the information in the table below and attach supporting documentation.”

Means-Tested Benefit Recipients: Full Name of Person Receiving the Benefit, Relationship to You, Name of Agency Awarding Benefit, Type of Benefit, Date Benefit was Awarded, Date Benefit Expires (or must be renewed)

If you selected Item Number 1.B. in Part 1., complete this section.

Provide information about your adjusted gross income.

If you are currently unemployed, are you currently receiving unemployment benefits? Yes No

What is your total household size? What is the total number of household members earning income including yourself?

Provide information about your adjusted gross income and the adjusted gross income of all family members counted as part of your household. You must list all amounts in U.S. dollars.

Provide the annual adjusted gross income of all family members counted as part of your household. (Do not include the amount provided in Item Number 6.)

Item Number 8. Total Adjusted Gross Household Income (add the amounts from Item Numbers 6. and 7.)

Has anything changed since the date you filed your Federal tax returns or is there any difference in your circumstances from the information on your petition? “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.

If you selected Item Number 1.C. in Part 1., complete this section.

You may also use this space to provide any additional information about your circumstances that you would like U.S. Citizenship and Immigration Services (USCIS) to consider. “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.

“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.)

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.

If the person listed in Part 2. is under 14 years of age, a parent or legal guardian may sign on their behalf.

NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.

Select the box for either Item A. orB. in Item Number 1. If applicable, select the box for Item Number 2.

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.

“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.”

“I certify that the information provided by the requestor in Part 7. applies to the household members identified in Part 3.”

Requestor's Signature Date of Signature (mm/dd/yyyy)

WARNING: If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-912, USCIS will deny your fee waiver request and may deny any other immigration benefit. In addition, you may face severe penalties provided by law and may be subject to criminal prosecution.

NOTE TO ALL REQUESTORS: If you do not completely fill out this request or fail to submit required documents listed in the Instructions, USCIS may deny your request.

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.

I am not an attorney or accredited representative but have prepared this request on behalf of the requestor and with the requestor's consent.

If you need extra space to complete any section of this request or if you would like to provide additional information about your circumstances, use the space provided in Part 10. Additional Information. Complete and submit as many copies of Part 10., as necessary, with your request.

“If you need more space than what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of paper.” Include your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers.