USCIS Fee Waiver Form I-912
Form I-912, Request for
Fee Waiver
Department of Homeland Security
U.S. Citizenship and Immigration Services
OMB No. 1615-0116; Expires 10/31/2012
Before you fill out this form, please read the instructions.
For USCIS Use Only
Family Name (Last Name)
Given Name (First Name)
Middle Initial
Alien Registration Number
A
U.S. Social Security Number
(SSN) (9 numbers only)
Date of Birth
(mm/dd/yyyy)
Marital Status
Never Married
Married
Approved
Signature of
Approving Officer
Denied
Officer's Comments
Line 1. a.
Line 1. b.
Line 1. c.
Line 2.
Line 3.
Line 4.
Line 5.
Line 6.
Section 1. Information About You
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 if Dependent(s) are Included in This Request
Form I-912 11/23/10
Widow(er)
Marriage Annulled
Divorced
Legally Separated
Biometric services fees, where applicable, will be
included in the request.
Line 7. 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)
SSN
(If applicable)
Date of Birth
(mm/dd/yyyy)
Relationship
to You
A-
A-
A-
A-
A-
A-
A-
(A-Number) (numbers only)
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