U.S. Department of Justice Executive Office for Immigration Review Board of Immigration Appeals OMB# 1125-0003 Fee Waiver Request Name: Alien Number ("A" Number): If more than one alien is included in your appeal or motion, only the lead alien need file this form. This form is to be signed by the alien, not the alien's attorney or representative of record. I, , declare under penalty of perjury, pursuant to 28 U.S.C. section 1746, that I am the person above and that I am unable to pay the fee. I believe that my appeal/motion is valid, and I declare that the following information is true and correct to the best of my knowledge: Assets Wages, Salary $ /month /month Expenses (including dependents) Housing (rent, mortgage, etc.) Food Medical/Health Utilities (phone, electric, gas, water, etc.) Transportation Debts, Liabilities /month Other (specify) _________________________ Signature of Alien $ $ $ $ /month /month /month /month $ Other Income (business, professional services, selfemployed/independent contracting, rental payments, etc.) Cash Checking and/or Savings Property (real estate, automobile(s), stocks, bonds, etc.) $ $ $ $ $ $ /month /month /month $ Other Financial Support (public assistance, alimony, child support, gift, parent, spouse, other family members, etc.) ________________ Date Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. The estimated average time to complete this form is one (1) hour. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Executive Office for Immigration Review, Office of the General Counsel, 5107 Leesburg Pike, Suite 2600, Falls Church, Virginia 22041. Privacy Act Notice The information on this form is requested to determine if you have established eligibility for the fee waiver you are seeking. The legal right to ask for this information is located at 8 C.F.R. § 1003.8(a)(3). EOIR may provide this information to other Government agencies. Failure to provide this information may result in denial of your request. Attorney or Representative (if any): I hereby attest that I have reviewed the details provided herein and I am satisfied that this fee waiver request is made in good faith. _____________________________________ Signature of Attorney or Representative _____________________________________ Print Name Form EOIR-26A Rev. July 2015 American LegalNet, Inc. www.FormsWorkFlow.com ________________ Date