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Instructions for Request for Fee Waiver  
USCIS  
Form I-912  
OMB No. 1615-0116  
Expires 02/28/2026  
Department of Homeland Security  
U.S. Citizenship and Immigration Services  
What Is the Purpose of Form I-912?  
You may request a fee waiver if you are unable to pay the filing fees or biometric services fees for an application or  
petition that is eligible for a fee waiver. When you request a fee waiver, you must clearly demonstrate that you are unable  
to pay the fees. For purposes of this form, the Requestor is the primary applicant or petitioner requesting the immigration  
benefit and fee waiver. The Requestor can also be the parent or legal guardian of a child or person with a physical,  
developmental, or mental disability who is the primary applicant or petitioner. If an individual is under 14 years of age, a  
parent or legal guardian may sign the request on behalf of that person.  
Please note the Form I-912 must be submitted in the name of the primary applicant requesting the immigration benefit fee  
and waiver.  
You can find the list of applications and petitions that are eligible for a fee waiver at www.uscis.gov/I-912 or refer  
to 8 CFR 106.3(a)(3). For filing tips and additional information, see www.uscis.gov/forms/filing-fees/additional-  
You do not need to submit Form I-912 for an application or petition that does not require a filing fee or if you qualify for  
a fee exemption based on your immigration status. See Form G-1055, available at www.uscis.gov/forms, for specific  
information about the fee exemptions available.  
Forms Eligible for Fee Waiver  
Below is a list of applications and petitions U.S. Citizenship and Immigration Services (USCIS) will consider for a fee  
waiver and the conditions that must be met to be eligible for a fee waiver. Under current fee waiver regulations, USCIS  
can only approve fee waivers for certain forms or certain filings of a particular form type, when fee waiver requirements  
are met.  
You may file this form to request a fee waiver for any of the following benefit requests or services:  
Application to Replace Permanent Resident Card (Form I-90);  
Application for Relief Under Former Section 212(c) of the Immigration and Nationality Act (INA) (Form I-191);  
Petition to Remove Conditions on Residence (Form I-751);  
Application for Family Unity Benefits (Form I-817);  
Application for Suspension of Deportation or Special Rule Cancellation of Removal (Form I-881) (Pursuant to  
Section 203 of Public Law 105 - 110 NACARA );  
Application to File Declaration of Intention (Form N-300);  
Request for a Hearing on a Decision in Naturalization Proceedings (Under Section 336 of the INA) (Form N-336);  
Application for Naturalization (Form N-400);  
Application to Preserve Residence for Naturalization Purposes (N-470);  
Application for Replacement Naturalization/Citizenship Document (N-565);  
Application for Certificate of Citizenship (N-600); and  
Application for Citizenship and Issuance of Certificate Under Section 322 (N-600K).  
Form I-912 Instructions 04/01/24  
Page 1 of 12  
For the following forms under certain conditions:  
Petition for a CNMI-Only Nonimmigrant Transitional Worker (Form I-129CW) E-2 CNMI investor;  
Petition for Nonimmigrant Worker (Form I-129) only in the case of a noncitizen applying for E-2 CNMI Investor for  
an extension of stay;  
Application to Extend/Change Nonimmigrant Status (Form I-539), only in the case of a noncitizen applying for CW-2  
nonimmigrant status or in the case of a noncitizen applying for E-2 CNMI Investor for an extension of stay;  
Application for Travel Document (Form I-131), when filed to request humanitarian parole;  
Notice of Appeal or Motion (Form I-290B), when there is no fee for the underlying application or petition or when the  
fee for the underlying application or petition may be waived;  
Notice of Appeal of Decision Under Section 210 or 245A of the Immigration and Nationality Act (Form I-694), if the  
underlying application or petition was fee exempt, the filing fee was waived, or was eligible for a fee waiver;  
Application for Employment Authorization (Form I-765), except persons filing under category (c)(33), Deferred  
Action for Childhood Arrivals (DACA); and  
Application for Temporary Protected Status (Form I-821) and associated biometric services fee, when filed as a first-  
time applicant.  
For the following forms if the applicant is exempt from public charge ground of inadmissibility under INA section 212(a)  
(4):  
Application for Advance Permission to Enter as a Nonimmigrant (Form I-192);  
Application for Waiver of Passport and/or Visa (Form I-193);  
Application to Register Permanent Residence or Adjust Status (Form I-485); and  
Application for Waiver of Grounds of Inadmissibility (Form I-601).  
If not otherwise fee exempt, you may apply for a fee waiver for ANY application or petition that is related to status as a:  
1. Battered spouse of A, G, E-3, or H nonimmigrant;  
2. Battered spouse or child of a lawful permanent resident or U.S. citizen under INA section 240A(b)(2);  
3. T nonimmigrant;  
4. Temporary Protected Status;  
5. U nonimmigrant; or  
6. VAWA self–petitioner and derivative(s);  
7. Conditional permanent resident (CPR) filing a waiver of the joint filing requirement based on battery or extreme  
cruelty;  
8. Abused spouses and children adjusting status under the Cuban Adjustment Act (CAA) and Haitian Refugee  
Immigration Fairness Act of 1998 (HRIFA);  
9. Abused spouses and children seeking benefits under Nicaraguan Adjustment and Central American Relief Act  
(NACARA);  
10. Special Immigrant Juveniles;  
11. Asylees; or  
12. Refugees.  
Form I-912 Instructions 04/01/24  
Page 2 of 12  
You may not file Form I-912 if you are requesting consideration for DACA. There are no fee waivers for DACA. Fee  
exemptions will be available in limited circumstances. See the Deferred Action for Childhood Arrivals Fee exemption  
How to File Form I-912  
You must file this fee waiver request with all applications and petitions for which you are requesting a fee waiver. If you  
are filing joint forms that have fees (for example, I-485 and I-765), you only need to file one Form I-912. You do not have  
to file a separate Form I-912 for the filing fee and the biometric services fee (if applicable).  
You may file one Form I-912 for all family-related applications or petitions filed at the same time. For example, if you file  
Form I-765, Application for Employment Authorization, and your spouse and children are filing separate Form I-765s at  
the same time, you only need to file one Form I-912 for all Form I-765s. You must send all forms together.  
General Instructions  
We provide free forms through the USCIS website. To view, print, or complete our forms, you should use the latest  
version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. If you do not have internet  
access, you may call the USCIS Contact Center and ask that we mail a form to you.  
Signature. You (or your signing authority) must properly complete your request. USCIS will not accept a stamped or  
typewritten name in place of any signature on this request. If you are under 14 years of age, your parent or legal guardian  
may sign the request on your behalf. A legal guardian may also sign for a mentally incompetent person. If your request is  
not signed, or if the signature is not valid, we will reject your request. See 8 CFR 103.2(a)(7)(ii)(A). If USCIS accepts a  
request for adjudication and determines that it has a deficient signature, USCIS may deny the request.  
Validity of Signatures. USCIS will consider a photocopied, faxed, or scanned copy of an original handwritten signature  
as valid for filing purposes. The photocopy, fax, or scan must be of the original document containing the handwritten ink  
signature.  
Evidence. When you file your request, you must submit all evidence and supporting documents listed in the Specific  
Instructions section of these Instructions.  
Copies. You should submit legible photocopies of requested documents unless the Instructions specifically instruct you to  
submit an original document. USCIS may request an original document at any time during our process. If we request an  
original document from you, we will return it to you after USCIS determines it no longer needs the original.  
NOTE: If you submit original documents when they are not required or requested, USCIS may destroy them after we  
receive them.  
Translations. If you submit a document with information in a foreign language, you must also submit a full English  
translation. The translator must sign a certification that the English language translation is complete and accurate, and that  
they are competent to translate from the foreign language into English. The certification must also include their signature,  
printed name, the signature date, and their contact information.  
USCIS Contact Center. For additional information on the request and Instructions about where to file, change of  
address, and other questions, visit the USCIS Contact Center at www.uscis.gov/contactcenter or call at 800-375-5283  
(TTY 800-767-1833). The USCIS Contact Center provides information in English and Spanish.  
Form I-912 Instructions 04/01/24  
Page 3 of 12  
Disability Accommodations/Modifications. To request a disability accommodation/modification, follow the instructions  
on your appointment notice or at www.uscis.gov/accommodationsinfo.  
How To Complete Form I-912  
1. Type or print legibly in black ink.  
2. If you need extra space to complete any item within this request, use the space provided in Part 10. Additional  
Information or attach a separate sheet of paper. Type or print your name and Alien Registration Number (A-Number)  
(if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer  
refers; and sign and date each sheet.  
3. Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been  
married and the question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise  
directed. If your answer to a question which requires a numeric response is zero or none (for example, “How many  
children do you have” or “How many times have you departed the United States”), type or print “None” unless  
otherwise directed.  
Specific Instructions  
Part 1. Basis for Your Request  
Item Number 1. Select a basis for your request. You are not required to complete the entire section of this request.  
Rather, select one basis or more for which you may qualify and complete the corresponding section as explained below in  
Parts 4., 5., and 6.  
Item Number 2. Provide your current immigrant or nonimmigrant status.  
Part 2. Information About You (Requestor)  
Item Number 1. Select if you are a parent or legal guardian filing on behalf of the person seeking the fee waiver.  
Item Number 2. Full Name. Provide your full name. If you have two last names, include both in the Family Name box  
and use a hyphen (-) if appropriate. If you do not have a middle name, type or print “N/A.”  
Item Number 3. Other Names Used (if any). Provide all other names you have used, including your maiden name.  
Item Number 4. Alien Registration Number (A-Number) (if any). Provide your A-Number. We use your A-Number  
to identify your immigration records. It begins with an “A” and can be found on correspondence you have received from  
the Department of Homeland Security (DHS) or USCIS. If you do not have an A-Number, type or print “N/A.”  
Item Number 5. USCIS Online Account Number. You will only have a USCIS Online Account Number (OAN) if you  
previously filed a form that has a receipt number that begins with IOE. If you filed the form online, you can find your  
OAN in your account profile. If you mailed us the form, you can find your OAN at the top of the Account Access Notice  
we sent you. If you do not have a receipt number that begins with IOE, you do not have an OAN. The OAN is not the  
same as an A-Number.  
Item Number 6. Date of Birth (mm/dd/yyyy). Provide your date of birth in mm/dd/yyyy format. For example, enter  
May 1, 1979, as 05/01/1979.  
Item Number 7. U.S. Social Security Number (if any). Provide your U.S. Social Security number. If you do not have a  
U.S. Social Security number, type or print “N/A.”  
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Page 4 of 12  
Item Number 8. Marital Status. Indicate your current marital status.  
Part 3. Applications and Petitions for Which You are Requesting a Fee Waiver  
Item Number 1. Complete the table for yourself and each person requesting a fee waiver with you. Provide the form  
numbers and the total number of applications and petitions for which you and any family members are requesting a fee  
waiver.  
Part 4. Means-Tested Benefits  
Item Number 1. If you, your spouse, your parent (if you are under 21 or disabled), or your child living with you receives  
a means-tested benefit, complete the table. You must attach supporting documentation. If you provide sufficient proof  
that you or your qualifying family member receive a means-tested benefit, your fee waiver will generally be approved.  
A means-tested benefit is a public benefit where a person’s eligibility for the benefit, the amount of the benefit, or both,  
is based on the person’s income and resources. USCIS will consider means-tested benefits that are Federally, state, or  
locally funded and granted by the benefit agency.  
Examples of means-tested benefit programs are Medicaid, Supplemental Nutrition Assistance Program (known as  
“SNAP” and formerly called Food Stamps), Temporary Assistance to Needy Families (TANF), and Supplemental Security  
Income (SSI), or other public assistance. Consult with your benefit-granting agency or your legal advisor to determine  
whether any Federal, state, or local public benefit that you may receive qualifies as a means-tested benefit.  
For the purposes of determining an inability to pay the filing fee of the petition or application, the following are not  
considered means-tested benefits: Medicare; unemployment benefits; Social Security retirement benefits; Social Security  
Disability Insurance (SSDI); Social Security Retirement, Survivors, and Disability Insurance (RSDI); or student financial  
aid.  
1. Individual Receipt of a Means-Tested Benefit  
A. The individual must demonstrate personal receipt of a means-tested benefit. When a parent is residing with a  
child who is receiving public housing or Section 8 benefits, Medicaid, Supplemental Nutrition Assistance Program  
(SNAP), Temporary Assistance for Needy Families (TANF), or Supplemental Security Income (SSI), the parent is  
also considered to be receiving the means-tested benefit.  
B. If a child is the sole applicant, the child may provide an individual means-tested benefit or a custodial parent’s  
means-tested benefit, if living in the same household.  
C. If multiple children are filing at the same time, each child must have an individual receipt of a means-tested  
benefit or be under the parent’s household who is receiving a means-tested benefit. USCIS considers children  
living in the same household to be receiving the means-tested benefit if the parent(s) are also living in the same  
household.  
2. Family Member’s Means-Tested Benefits  
A. Your spouse and unmarried children under 21 years of age living with you will normally qualify for a fee waiver  
as part of your household if you are receiving means-tested benefits.  
B. If your spouse is receiving a means-tested benefit, you will normally qualify for a fee waiver as long as you are  
residing with your spouse and are not legally separated.  
C. You may use a child’s public housing or Section 8 subsidy, Medicaid, SNAP, TANF, or SSI if the child is living in  
the same household.  
D. If you are 21 years of age or older, you cannot use a parents means-tested benefits (such as SSI), even if the  
parent is living with you, as evidence of your eligibility for a fee waiver unless you are disabled and your parent  
is your legal guardian or surrogate. However, you may use information about your parent’s means-tested benefits  
to support a fee waiver request under Part 6. Financial Hardship if the award letter or benefit approval document  
indicates the total household income and you are otherwise eligible under those criteria.  
Form I-912 Instructions 04/01/24  
Page 5 of 12  
3. Documentation  
A. To qualify for a fee waiver, the evidence that you provide must demonstrate that you are currently receiving the  
means-tested benefit. This evidence can be in the form of a letter, notice, or other agency documents that indicate  
that the benefit is being received.  
B. Documentation must contain:  
(1) Your name (or the name of the person receiving the benefit);  
(2) The name of the agency granting the public benefit;  
(3) The type of benefit; and  
(4) An indication that the benefit is currently being received (for example, a recently dated letter or document  
with effective dates, date of renewal or period the approval ends, if available).  
C. If the documentation is more than 12 months old and the benefit is still being received, provide additional  
evidence that shows the benefit is currently being received.  
Part 5. Income at or Below 150 Percent of the Federal Poverty Guidelines  
To qualify for the fee waiver, your adjusted gross household income must be at or below 150 percent of the Federal Poverty  
Guidelines, at the time of filing, based on your household size. The Federal Poverty Guidelines are established by the  
Secretary of the Department of Health and Human Services annually. To obtain information on the current Federal Poverty  
Guidelines, visit our Web site at www.uscis.gov/I-912P and review Form I-912P, Poverty Guidelines for Fee Waiver  
Request.  
Your Employment Status  
Item Number 1. Employment Status. Indicate your current employment status. If you are both employed and a student,  
select Other and provide an explanation.  
Item Number 2. Indicate if you are currently receiving unemployment benefits. If applicable, provide the date that you  
became unemployed and include the total amount of unemployment benefits you have received in Item Number 7.  
Item Number 3. Indicate the total number of people living in your household. If you are applying for any immigration  
benefits (such as for adjustment of status) based on a pending or approved petition or application for VAWA benefits or T  
or U nonimmigrant status and your head of household, the person upon whose tax return you are listed as a dependent, or  
one of your household members is or was your abuser or human trafficker, do not list that person in Item Numbers 3 - 5.  
or their income in Item Numbers 6. - 8. below.  
Household members include the following people, who are dependent on your income, your spouse’s income, or the head  
of household’s income, as part of your household size:  
1. You;  
2. The head of your household (if not you). If the child is applying individually, provide the information of the primary  
custodial parent;  
A. You are the head of household if you filed the most recent Federal tax return for your household (includes filing as  
head of household) or earned the majority of the income for your household.  
B. If you are not the head of household, the head of household is the person who filed the most recent Federal  
tax return on which you are listed as a dependent or the person who provides the majority of your household’s  
income. If you already have or are applying for Special Immigrant Juvenile (SIJ) classification, do not include  
any foster or group home household members.  
3. Your spouse, if living with you (if you are separated or your spouse is not living with you, do not include your  
spouse); or  
Form I-912 Instructions 04/01/24  
Page 6 of 12  
4. Any family members living in your household who are dependent on your income, your spouse’s income, or the head  
of household’s income, including:  
A. Your children or legal wards who are unmarried and under 21 years of age, and who live with you;  
B. Your children or legal wards who are unmarried, are over 21 years of age but under 24 years of age, are full-time  
students, and who live with you when not at school;  
C. Your children or legal wards who are unmarried and for whom you are the legal guardian because they are  
physically or developmentally disabled or mentally impaired to the extent that they cannot adequately care for  
themselves and cannot establish, maintain, or re-establish their own household;  
D. Your parents who live with you; and  
E. Any other dependents listed on your Federal tax return or your spouse or head of household’s Federal tax returns.  
Item Number 4. Indicate the total number of people living in your household who are earning income, including  
yourself.  
Item Number 5. Provide the name of the head of household for your household if it is someone other than you.  
Your Annual Adjusted Household Income  
Item Number 6. Your Annual Income. Provide information on your annual income. If you filed a Federal tax return,  
enter the amount from Line 37 (adjusted gross income) on Internal Revenue Service (IRS) Form 1040, U.S. Individual  
Income Tax Return. If you have not filed a Federal tax return, take your total household wage income (before any  
deductions) for the previous 12-month period and enter that amount as your household’s annual income. If you have  
not filed a Federal income tax return but you have an IRS Form W-2, Wage and Tax Statement, that covers the previous  
12-month period, take your total wage income, deduct Federal, state, and local income taxes withheld, and enter that  
amount as your household’s annual wage income.  
Documentation. To document your annual income, provide copies of the following:  
1. A copy of your most recent Federal tax return, if available;  
2. If you did not file a Federal tax return, or if your Federal tax return does not properly reflect your current income,  
submit copies of consecutive pay statements (stubs) for a minimum of the past month, recent Form W-2, Form SSA-  
1099, or statements from your employers on business stationery showing salary or wages paid;  
3. If you are a student and not living with your parents or are not claimed as a dependent on your parents’ Federal  
tax return, do not include your parents’ incomes. You should only provide proof of your income or documentation  
that shows you are not required to file a Federal or state tax return, such as proof that you are a full-time student as  
supporting documentation;  
4. If you are recently unemployed, and your annual income on your Federal tax return or other proof of income is above  
150 percent of the Federal Poverty Guidelines, describe your particular situation that you believe qualifies you for a  
fee waiver in Part 5., Item Number 9. Provide information regarding any unemployment benefits you are currently  
receiving;  
5. If you do not have any income, financial support, or cannot provide evidence of income, describe your particular  
situation that you believe qualifies you for a fee waiver in Part 5., Item Number 9. If available, you may submit  
affidavits from, for example, religious institutions, non-profits, community-based organizations, or similarly  
recognized organizations, indicating that you are currently receiving some benefit or support from the organization  
verifying (or attesting to) your situation.  
Form I-912 Instructions 04/01/24  
Page 7 of 12  
Item Number 7. Annual Adjusted Income of All Household Members. Provide the annual income from all family  
members counted as part of your household.  
1. If a person lives with you, but does not contribute financial support to your household, then you should not include  
this person’s income when calculating your household income.  
2. If you are separated or still married, but do not live with your spouse, do not include your spouse’s income. However,  
you must include any financial support your spouse provides to your household.  
3. You must include any ongoing additional income or additional financial assistance that you or your household  
members receive and provide documentation that is not otherwise listed in your taxes. If you do not have  
documentation of your additional income or additional financial assistance then you must provide an explanation in  
Part 10. Additional Information.  
4. If you are applying for any immigration benefits (such as for adjustment of status) based on the Violence Against  
Women Act (VAWA), or T or U nonimmigrant status under the Victims of Violence and Trafficking Protection  
Reauthorization Act, do not provide your spouse’s income. You do not need to include as a household member or  
provide income for:  
Any person in the household who is or was the requestor’s abuser, human trafficker, or perpetrator; or  
A person who is or was a member of the abuser, human trafficker, or perpetrator’s household.  
5. If you are a full-time student, over 21 years of age but under 24 years of age, are unmarried, and are living with your  
parents, or you are claimed as a dependent on your parents’ Federal tax return, include your parents’ income. You  
must provide a copy of both parents’ Federal tax returns and your own Federal tax return, or provide proof of income  
as supporting documentation.  
6. If members of your household are recently unemployed, and your annual household income on your Federal tax return  
or other proof of income is above 150 percent of the Federal Poverty Guidelines, describe your particular situation  
that you believe qualifies you for a fee waiver in Part 5., Item Number 9.  
Documentation. To document your household members’ incomes, provide the following:  
1. A copy of each household member’s most recent Federal tax return, if available;  
2. If the household member did not file a Federal tax return, or if the tax return does not properly reflect their current  
income, submit copies of consecutive pay statements (stubs) for a minimum of the past month, a recent Form W-2,  
Form SSA-1099, or employer statements on business stationery showing salary or wages paid; or  
3. If you do not have any income or cannot provide evidence of income for your household, describe your particular  
situation in Part 5., Item Number 9. If applicable, you may submit affidavits from religious institutions, non-profits,  
or community-based organizations verifying that you are currently receiving some benefit or support from them.  
In addition, if no unemployment compensation is being received, you may submit a letter of termination from the  
employer.  
You must document additional financial assistance as income. Include the following information:  
1. Documentation such as parental support; alimony; child support; educational stipends; pensions; Social Security;  
royalties, pensions, veterans benefits; unemployment benefits; and consistent or regular financial support from adult  
children, parents, dependents, or other people living in your household.  
2. A court order of any child support or documentation that indicates the actual amount of child support amount being  
received (for example, bank statements or IRS Form W-2), or documentation from an agency providing the other  
income or financial assistance.  
3. A copy of your most recent Federal tax return, if available. If you are receiving unemployment benefits, the tax  
document, IRS Form 1099-MISC, is not enough to establish total income. Provide information regarding any  
unemployment benefits you are currently receiving in Part 5., Item Number 9.  
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Page 8 of 12  
Item Number 8. Total Adjusted Gross Household Income. Provide the total household income. Add the amounts from  
Item Numbers 5., 6., and 7. USCIS will compare this amount to the Federal Poverty Guidelines.  
If you do not have any income, financial support, or cannot provide evidence of income, describe your particular situation  
that you believe qualifies you for a fee waiver in Part 5., Item Number 9. If applicable, you may submit affidavits from  
religious institutions, non-profits, or community-based organizations verifying that you are currently receiving some  
benefit or support from them.  
Item Number 9. Indicate whether any information (including marital status, income, and list of dependents) in  
your Federal tax return is different from what you indicate in Form I-912. Provide the reasons for any changes in  
circumstances and any differences between the tax returns and information in your Form I-912. If you need to explain  
anything else about your circumstances that affect the income determination, use the space provided in Part 10.  
Additional Information.  
Part 6. Financial Hardship  
Item Number 1. Provide details about your financial hardship. This may include, but is not limited to:  
Medical bills for yourself, spouse, child or parent.  
Letter of termination or receipt of unemployment benefits.  
Pay statements indicating change in income.  
Letter of eviction.  
Letter from homeless shelter services or statement of lack of income.  
Military Deployment orders.  
Documentary assistance from Federal Emergency Management Agency (FEMA) or other assistance, insurance  
documents.  
Documentation of insurance documentation or assistance from FEMA or other program.  
Documentation of bills for utilities and mortgages.  
Documentation of income.  
Documentation of substantial financial losses.  
Victimization - provide receipt notice for filing under VAWA, T, or U category.  
Divorce decree or death certificate and documentation of income loss.  
You may also complete this section if your income is above 150 percent of the Federal Poverty Guidelines as defined in  
Part 5. and you believe you have special circumstances that warrant a fee waiver.  
Documentation. Provide documentation related to your financial hardship including information on income and the  
following based on the type of circumstance:  
Medical bills for yourself, spouse, child or parent.  
Letter of termination or receipt of unemployment benefits.  
Pay statements indicating change in income.  
Letter of eviction.  
Letter from homeless shelter services or statement of lack of income.  
Military Deployment orders.  
Documentation of insurance or assistance from Federal Emergency Management Agency (FEMA) or other program.  
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Page 9 of 12  
Documentation of bills for utilities and mortgages.  
Documentation of income.  
Documentation of substantial financial losses.  
Victimization - provide receipt notice for filing under VAWA, T, or U category.  
Divorce decree or death certificate and documentation of income loss.  
Item Number 2. List the types of assets you have, the dollar value of those assets, and the total dollar value of your  
assets. Include the following assets:  
1. Cash, checking and savings accounts, annuities, stocks, and bonds. These are assets that easily covert into cash; and  
2. Other property or assets that you can easily convert into cash without incurring a hardship.  
Do not include your retirement account (401K plans or Individual Retirement Accounts (IRA)) as assets unless this is your  
sole means of income.  
Documentation. You must document your income and provide a complete list, description, and an estimate of the value  
of your assets that you can easily convert into cash and any liabilities.  
Item Number 3. Total Monthly Expenses and Liabilities. Provide your average monthly costs for all applicable  
categories provided.  
Documentation. Provide evidence, where possible, such as copies of monthly bills and payments, and documentation for  
monthly expenses and any extenuating circumstances, such as medical bills. If you cannot provide evidence of income,  
you may submit affidavits from religious institutions, non-profits, or community-based organizations verifying that you  
are currently receiving some benefit or support from them.  
Part 7. Requestor’s Statement, Contact Information, Certification, and Signature  
Item Numbers 1. - 6. Select the appropriate box to indicate whether you read this request yourself or whether you had  
an interpreter assist you. If someone assisted you in completing the request, select the box indicating that you used a  
preparer. Further, you must sign and date your request and provide your daytime telephone number, mobile telephone  
number (if any), and email address (if any). Every request MUST contain the signature of the requestor (or parent or legal  
guardian, if applicable). A stamped or typewritten name in place of a signature is not acceptable.  
Part 8. Interpreter’s Contact Information, Certification, and Signature  
Item Numbers 1. - 7. If you used anyone as an interpreter to read the Instructions and questions on this request to you in  
a language in which you are fluent, the interpreter must fill out this section, provide his or her name, the name and address  
of his or her business or organization (if any), his or her daytime telephone number, his or her mobile telephone number  
(if any), and his or her email address (if any). The interpreter must sign and date the request.  
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Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Request, if Other Than the  
Requestor  
Item Numbers 1. - 8. This section must contain the signature of the person who completed your request, if other than  
you, the requestor. If the same individual acted as your interpreter and your preparer, that person should complete both  
Part 8. and Part 9. If the person who completed this request is associated with a business or organization, that person  
should complete the business or organization name and address information. Anyone who helped you complete this  
request MUST sign and date the request. A stamped or typewritten name in place of a signature is not acceptable. If the  
person who helped you prepare your request is an attorney or accredited representative, he or she may be obliged to also  
submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or Form G-28I,  
Notice of Entry of Appearance as Attorney In Matters Outside the Geographic Confines of the United States, along with  
your request.  
Part 10. Additional Information  
Item Numbers 1. - 6. If you need extra space to provide any additional information within this request, use the space  
provided in Part 10. Additional Information. If you need more space than what is provided in Part 10., you may make  
copies of Part 10. to complete and file with your request, or attach a separate sheet of paper. Type or print your name and  
A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your  
answer refers; and sign and date each sheet.  
We recommend that you print or save a copy of your completed request for your records.  
Where To File?  
Mail your Form I-912, along with the completed USCIS applications or petitions, and all supporting documentation  
according to the Where to File section in the Instructions of the application or petitions for which you are requesting a fee  
waiver.  
Address Change  
If you are not a U.S. citizen, you must notify USCIS of your new address within 10 days of moving from your previous  
residence. For information on changing your address, go to our website at www.uscis.gov/addresschange, or call the  
USCIS Contact Center.  
NOTE: Do not submit a change of address request to the USCIS Lockbox.  
Processing Information  
Decision. The decision on Form I-912 involves a determination of whether you have established eligibility for the fee  
waiver. USCIS will notify you of the decision in writing. If USCIS denies your fee waiver request, the notice will include  
information on resubmitting your application or petition. For certain immigration benefits, you may have only a limited  
period of time in which to resubmit your application or petition with the proper filing fee. Please review the Instructions  
for the application or petition for which you want USCIS to consider a fee waiver to determine when to refile.  
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USCIS Forms and Information  
To ensure you are using the latest version of this request, visit www.uscis.gov.  
Penalties  
If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-912, we will  
deny your fee waiver request and may deny any other immigration benefit. In addition, you may face severe penalties  
provided by law and may be subject to criminal prosecution.  
DHS Privacy Notice  
AUTHORITIES: The information requested on this request, and the associated evidence, is collected under the  
Immigration and Nationality Act sections 286 and 8 CFR 106.3.  
PURPOSE: The primary purpose for providing the requested information on this form is to determine if you have  
established eligibility for a fee waiver for the associated immigration benefit in which you are filing. The Department of  
Homeland Security (DHS) uses the information you provide to grant or deny the immigration benefit you are seeking  
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and  
any requested evidence, may delay a final decision in your case or result in denial of your request and rejection of your  
application or petition based on non-payment of the filing fee.  
ROUTINE USES: DHS may share the information you provide on this request with other Federal, state, local, and  
foreign government agencies and authorized organizations. DHS follows approved routine uses described in the  
associated published system of records notices [DHS-USCIS-007- Benefits Information System and DHS-USCIS-001-  
Alien File, Index, and National File Tracking System of Records] which you can find at www.dhs.gov/privacy. DHS  
may also share the information, as appropriate, for law enforcement purposes or in the interest of national security.  
Paperwork Reduction Act  
USCIS may not conduct or sponsor an information collection, and you are not required to respond to a collection  
of information, unless it displays a currently valid Office of Management and Budget (OMB) control number. The  
public reporting burden for this collection of information is estimated at 1.095 hours per response, including the time  
for reviewing instructions, gathering the required documentation and information, completing the request, preparing  
statements, attaching necessary documentation, and submitting the request. Send comments regarding this burden  
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S.  
Citizenship and Immigration Services, Office of Policy and Strategy, Regulatory Coordination Division, 5900 Capitol  
Gateway Drive, Mail Stop #2140, Camp Springs, MD 20588-0009; OMB No. 1615-0116. Do not mail your completed  
Form I-912 to this address.  
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