Request for Fee Waiver

• Legal Form Number: I-912
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-912 Edition 09/03/21 Page 1 of 11

Request for Fee Waiver

Department of Homeland Security

U.S. Citizenship and Immigration Services

For

USCIS

Use

Only

USCIS

Form I-912

OMB No. 1615-0116

Expires: 09/30/2024

START HERE - Type or print in black ink.►

Application Receipted At (Select only one box)

USCIS Field Office USCIS Service Center

Fee Waiver Approved

Date:______________

Fee Waiver Denied

Date:______________

Fee Waiver Approved

Date:______________

Fee Waiver Denied

Date:______________

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

Form I-912 Instructions)

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.)

1.

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.

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.

2.

3.

Family Name (Last Name) Given Name (First Name) Middle Name

1. Full Name

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.

Other Names Used (if any) 2.

Family Name (Last Name) Given Name (First Name) Middle Name

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

4. USCIS Online Account Number (if any)3. Alien Registration Number (A-Number) (if any)

A-

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Date of Birth (mm/dd/yyyy)5. 6. U.S. Social Security Number (if any)

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