Form I-942 02/13/19 Page 1 of 9 START HERE - Type or print in black ink. For USCIS Use Only Request Receipted At (Select only one box) USCIS Field Office USCIS Service Center Reduced Fee ApprovedDate:Reduced Fee DeniedDate:Reduced Fee ApprovedDate:Reduced Fee DeniedDate: Request for Reduced Fee Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-942 OMB No.1615-0133 Expires 02/28/2021 Family Name (Last Name)Given Name (First Name)Middle Name1. Full Name 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. Date of Birth (mm/dd/yyyy) 2.3.Alien Registration Number (A-Number)Marital Status4. Marriage AnnulledSingle, Never Married MarriedDivorcedWidowed Other (Explain) Separated A- Part 2. Information About Family Members Filing This Request With You1.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 StatusEmployment Status1. Other (Explain) RetiredEmployed (full-time, part-time, seasonal, self-employed) Unemployed or Not Employed American LegalNet, Inc. www.FormsWorkFlow.com Form I-942 02/13/19 Page 2 of 9 Information About Your Spouse2.If you are married or separated, does your spouse live in your household? Yes NoIf you answered 223No224 to Item Number 2., does your spouse provide any financial support to your household?A. Yes No Part 3. Household Income (continued) If you answered 223Yes224 to Item Number 3., type or print your name on the line marked 223self224 in the table below. If you answered 223No224 to Item Number 3., type or print your name on the line marked 223self224 in the table below and add the head of household's name on the line below yours. Household Size Full Name Full-Time Student Yes No Yes No Yes No Yes No Relationship to You Date of Birth Married Yes No Yes No Yes No Yes No Does Person Earn Income Counted Toward Household Income? Yes No Yes No Yes No Yes NoSelf Total Household Size (including self) 4.Your Annual Income5.Annual Income of All Household Members 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. Your Annual Household IncomeProvide the annual income of all family members counted as part of your household as listed above under Household Size in Item Number 3. (Do not include the amount provided in Item Number 4.)6.Total Additional Income or Financial Support Provide the total annual amount you receive in additional regular income or financial support from a source outside of your household. (Do not include the amount provided in Item Number 4. or 5.) You must add all of the additional income and financial support amounts that you regularly receive and put the total amount in the space provided. Type or print "0" in the total box if there is none. Select the type of additional income or financial support that you receive and provide documentation.Parental SupportSpousal Support (Alimony)Child SupportEducational StipendsRoyaltiesPensionsOther (Explain) UnemploymentSocial Security BenefitsVeteran's BenefitsFinancial Support From Adult Children, Dependents, Other People Living in the Household 7.Total Household Income (add the amounts from Item Numbers 4., 5., and 6.) 3.Are you the person providing the primary financial support for your household? Yes No Your Household Size American LegalNet, Inc. www.FormsWorkFlow.com Form I-942 02/13/19 Page 3 of 9 8.Has anything changed since the date you filed your Federal tax returns? (For example, your marital status, income, or number of dependents.) Yes NoIf you answered "Yes" to Item Number 8., provide an explanation below. Provide documentation if available. At my request, the preparer named in Part 7., Requestor's Statement Regarding the Preparer2.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. Part 4. Requestor's Statement, Contact Information, Certification, and Signature A.Requestor's Statement Regarding the Interpreter1.NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.The interpreter named in Part 6. read to me every question and instruction on this request, and my answer to every B., a language in which I am fluent, and I understood everything. NOTE: Read the Penalties section of the Form I-942 Instructions before completing this part. Requestor's Daytime Telephone Number 3.4.Requestor's Mobile Telephone Number (if any) Requestor's Contact Information Requestor's Email Address (if any)5. Requestor's Statementquestion in Part 3. Household Income (continued) ,prepared this request for me based only upon information I provided or authorized. Requestor's CertificationCopies 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.Each person applying for a reduced fee must complete, sign, and date Form I-942 and provide the required documentation. This includes family members identified in Part 2., Item Number 1. Signature fields for family members are at the end of this part. A legal guardian may sign the request on behalf of the applicant. USCIS rejects any Form I-942 that is not signed by all individuals requesting a reduced fee and may deny a request that does not provide the required documentation. If the information provided by the requestor in Part 4. is not applicable to a family member identified in Part 2., that individual should complete Part 5. American LegalNet, Inc. www.FormsWorkFlow.com Form I-942 02/13/19 Page 4 of 9 Part 4. Requestor's Statement, Contact Information, Certification, and Signature (continued) Requestor's Signature Requestor's SignatureDate of Signature (mm/dd/yyyy) 6.I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that: 1)I reviewed and provided or authorized all of the information in my request;2)I understood all of the information contained in, and submitted with, my request; and 3)All of this information was complete, true, and correct at the time of filing.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. Family Members' SignaturesNOTE: Each family member must type or print their full name and sign in the spaces below. You can find additional family members' signature spaces in Item Numbers 7. - 10. below. All family members identified in Part 2., Item Number 1. must sign and date Form I-942.I certify that the information provided by the requestor in Part 4. applies to me. Family Member's Name Family Member's NameFamily Member 1Family Member 27.8. Family Member's SignatureDate of Signature (mm/dd/yyyy) Family Member's SignatureDate of Signature (mm/dd/yyyy) Family Member's Name Family Member's NameFamily Member 3Family Member 49.10. Family Member's SignatureDate of Signature (mm/dd/yyyy) Family Member's SignatureDate of Signature (mm/dd/yyyy) NOTE TO ALL REQUESTORS: If you do not completely fill out this request or fail to submit required documents listed in the Instructions, USCIS ma