Request for Fee Waiver Department of Homeland Security U.S. Citizenship and Immigration Services Application Receipted At (Select only one box) For USCIS Use Only USCIS Field Office Fee Waiver Approved Date:______________ Fee Waiver Denied Date:______________ USCIS Service Center Fee Waiver Approved Date:______________ OMB No. 1615-0116 Expires: 04/30/2018 USCIS Form I-912 Fee Waiver Denied Date:______________ 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. 1. 2. 3. 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. - 10.) My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2. - 3., Part 5., and 7. - 10.) I have a financial hardship. (Complete Parts 2. -3. and Parts 6. - 10.) 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 Family Name (Last Name) 2. Other Names Used (if any) List all other names you have used, including nicknames, aliases, and maiden name. Family Name (Last Name) Given Name (First Name) Middle Name Given Name (First Name) Middle Name 3. 5. Alien Registration Number (A-Number) (if any) ADate of Birth (mm/dd/yyyy) 6. 4. USCIS Online Account Number (if any) U.S. Social Security Number (if any) American LegalNet, Inc. www.FormsWorkFlow.com Form I-912 04/25/16 Y Page 1 of 11 Part 2. Information About You (Requestor) (continued) 7. Marital Status Single, Never Married Other (Explain) Married Divorced Widowed Marriage Annulled Separated 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 Full Name A-Number (if any) Date of Birth Relationship to You Forms Being Filed AAAATotal 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 Full Name of Person Receiving the Benefit Relationship to You Name of Agency Awarding Benefit Type of Benefit Date Benefit Date Benefit Expires was Awarded (or must be renewed) Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines If you selected Item Number 2. in Part 1., complete this section. Your Employment Status 1. Employment Status Employed (full-time, part-time, seasonal, self-employed) Unemployed or Not Employed Retired Other (Explain) Form I-912 04/25/16 Y American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 11 Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines (continued) 2. If you are currently unemployed, are you currently receiving unemployment benefits? A. Date you became unemployed (mm/dd/yyyy) Yes No Information About Your Spouse 3. If you are married or separated, does your spouse live in your household? A. If you answered "No" to Item Number 3., does your spouse provide any financial support to your household? Yes Yes No No Your Household Size 4. Are you the person providing the primary financial support for your household? Yes No 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 Full Name Date of Birth Relationship to You Self Married Yes Yes Yes Yes No No No No Full-Time Student Yes Yes Yes Yes No No No No Is any income earned by this person counted towards the household income? Yes Yes Yes Yes No No No No 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. 5. 6. Your Annual Income Annual Income of All Family Members Provide the annual income of all family members counted as part of your household as listed in Item Number 4. (Do not include the amount provided in Item Number 5.) $ 7. Total Additional Income or Financial Support $ $ 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. Parental Support Spousal Support (Alimony) Child Support Educational Stipends Royalties Pensions Unemployment Benefits Social Security Benefits Veteran's Benefits Financial Support From Adul