Fee Waiver Form - USCIS

Family Name (Last Name)
Given Name (First Name)
Middle Initial
Date of Birth
Marital Status
Line 1. a.
Line 1. b.
Line 1. c.
Line 2.
Line 3.
Line 4.
Line 5.
Line 6.
Section 1. Information About You (Provide information about yourself. If you
are applying for a minor child, provide information about the minor child.)
Applications and Petitions (Enter the form number(s) of the application(s) and/or
petition(s) for which you are requesting a fee waiver.)
Section 2. Additional Information for Dependent(s)
Biometrics services fees, where applicable, will be included in the fee waiver request.
Complete the Table below if applicable. (If you need more space, attach a separate sheet of paper.)
Name (First, MI, Last) A-Number
(If applicable)
Is Individual
Included in Fee
Waiver Request?
Date of Birth
(mm/dd/yyyy)
Relationship to You
A-
A-
A-
A-
A-
A-
A-
Application Receipted At
(check only one box):
FOR USCIS USE ONLY
USCIS Field Office
Fee Waiver Approved
Fee Waiver Denied
USCIS Service Center
Fee Waiver Denied
Fee Waiver Approved
Date:______________
Date:______________
Date:______________
Date:______________
Alien Registration Number
Request for Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-912
OMB No. 1615-0116
Expires 05/31/2015
A-
(mm/dd/yyyy)
Never Married
Married
Divorced Marriage Annulled
Legally Separated
Widow(er)
No
Yes
No
Yes
No
Yes
NoYes
No
Yes
No
Yes
No
Yes
Form I-912 05/10/13 Y
Before you fill out this form, please read the instructions.
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