I-912 Fee Waiver

Not for official use, only for reference to fill out the official application

REASON FOR REQUESTING THE FEE WAIVER:

1. I currently receive/we currently receive State Benefits
2. My annual income is below 150% of the Federal Poverty Guidelines.
3. I currently have a financial hardship.

My income is below 150% of the Federal poverty level:

• Last tax return (Form 1040 duly signed).
• Last tax return of the members of the household who contribute to the overall income.
• If you do not have the last tax return, attach the most recent W2 and/or 1099 forms.

I receive Benefits

• All documentation about the benefit you receive, including the agency that grants it, type of benefit, start date, end date and amount.

Financial hardship

• Explanation about the situation
• Documents showing income
• Documents showing debts.