Form I 912 Waiver – Fill Out and Use This PDF

►START HERE - Type or print in black ink.

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 11. Additional Information.

Complete and submit as many copies of Part 11., as necessary, with your request.

Part 1. Basis for Your Request (Each basis is further explained in the Specific Instructions section of the

Form I-912 Instructions)

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.

Part 2. Information About You (Requestor)

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

1.Full Name

2.Other Names Used (if any)

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

Part 2. Information About You (Requestor) (continued)

Part 3. Applications and Petitions for Which You Are Requesting a Fee Waiver

1.In the table below, add the form numbers of the applications and petitions for which you are requesting a fee waiver.

Applications or Petitions for You and Your Family Members

Total Number of Forms (including self)

Part 4. Means-Tested Benefits

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

1.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. If you are the parent or legal guardian filing on behalf of a child or person with a physical disability or developmental or mental impairment, provide information about the child or person for whom you are filing this form if he or she is receiving a means-tested benefit.

Means-Tested Benefit Recipients

Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines

Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)

Your Household Size

If you answered “Yes” to Item Number 4., type or print your name on the line marked “self” in the table below. If you answered “No” to Item Number 4., type or print your name on the line marked “self” in the table below and add the head of household's name on the line below yours.

Household Size

Total Household Size (including self)

Your Annual Household Income

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

Provide the total annual amount you receive in additional income or financial support from a source outside of your household. (Do not include the amount provided in Item Numbers 5. or 6.) You must add all of the additional income and financial support amounts and put the total amount in the space provided. Type or print "0" in the total box if there are none. Select the type of additional income or financial support that you receive and provide documentation.

Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued)

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.

Part 6. Financial Hardship

If you selected Item Number 3. in Part 1., complete this section.

1.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. Examples may include medical expenses, job loss, eviction, and homelessness.

2.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.)

Assets

Total Value of Assets

Part 6. Financial Hardship (continued)

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.

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

and I understood everything.

Requestor's Contact Information

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.