OMB No. 1615-0116; Expires 10/31/2012 Form I-912, Request for Fee Waiver Department of Homeland Security U.S. Citizenship and Immigration Services Before you fill out this form, please read the instructions. For USCIS Use Only Section 1. Information About You Approved Line 1. a. Family Name (Last Name) Signature of Approving Officer Line 1. b. Given Name (First Name) Line 1. c. Middle Initial Line 2. Alien Registration Number A (A-Number) (numbers only) U.S. Social Security Number (SSN) (9 numbers only) Line 3. Line 4. Denied Officer's Comments Date of Birth (mm/dd/yyyy) Marital Status Line 6. Never Married Married Marriage Annulled Legally Separated Line 5. Divorced Widow(er) Applications and Petitions (Enter the form number(s) of the application(s) and/or petition(s) for which you are requesting a fee waiver. Biometric services fees, where applicable, will be included in the request. Section 2. Additional Information if Dependent(s) are Included in This Request Line 7. Complete the Table below if applicable. (If you need more space, attach a separate sheet of paper) Name (First, MI, Last) A-Number (If applicable) SSN (If applicable) Date of Birth (mm/dd/yyyy) Relationship to You AAAAAAA- Form I-912 11/23/10 American LegalNet, Inc. www.FormsWorkFlow.com Section 3. Basis for Your Request (Check any that apply) Line 8. a. a. I am receiving a means-tested benefit. (complete Section 4) Line 8. b. b. My household income is at or below 150% of the Federal Poverty Guidelines. (complete Section 5) Line 8. c. c. I have a financial hardship. (complete Section 6) Section 4. Means-Tested Benefit Line 9. Complete the Table Below (If you need more space, attach a separate sheet of paper) Name of Person Receiving the Benefit Name of Agency Awarding Benefit Date Benefit Was Awarded Are You Receiving This Benefit Now? Yes No Yes No Yes No Yes No Section 5. Household Income (Provide evidence of monthly income or other support) Line 10. How many dependents (for tax purposes) live with you? (round to the nearest dollar) Line 11. Average monthly wage income from household members Line 12. Other money received each month (child support, spousal support, unemployment, etc.) Total (USCIS will compare this amount to Federal Poverty Guidelines) Form I-912 11/23/10 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Section 6. Financial Hardship Line 13. Describe your particular situation. Be sure to include how this situation has caused you to incur costs (and what the costs were) or loss of income that you have experienced (and what that loss was). (If you need more space, attach a separate sheet of paper.) If unemployed: Line 14. Date that you became unemployed Line 15. Amount of unemployment compensation (monthly) that you are receiving (enter dollars) Line 16. List your assets and the value of your assets. (If you need more space, attach a separate sheet of paper.) Type of Asset Value (enter dollars) TOTAL Value of Assets Form I-912 11/23/10 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Section 6. Financial Hardship (Cont'd) List your average monthly cost, provide evidence of monthly payments where possible. (If you need more space, attach a separate sheet of paper.) Type of Cost Value (Enter Dollars) Type of Cost Rent Insurance Mortgage Loan Payment Food Commuting Costs Utilities Medical Child/Elder care Line 17. Value (Enter Dollars) School TOTAL Monthly Costs Section 7. Your Signature and Authorization Do not sign your Form I-912 until it is complete and you are ready to file. I take full responsibility for the accuracy of all the information provided, including all supporting documentation. I authorize the release of any information, including the release of my Federal tax returns, that USCIS needs to determine my eligibility. Each person applying for a fee waiver request must sign Form I-912. This includes individuals identified in Sections 1 and 2 if 14 years of age or older. Line 18. Your Signature Date Additional Signature Date Additional Signature Date Additional Signature Date Additional Signature Date Additional Signature Date Form I-912 11/23/10 Page 4 American LegalNet, Inc. www.FormsWorkFlow.com