Part 7: Requestor's Statement, Contact Information, Certification, and Signature

The person whose information is provided in Part 2 may sign on behalf of the entire household. If the person listed in Part 2 is under 14 years of age, a parent or legal guardian may sign on their behalf.

NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part.

Select either A or B in Item 1. If applicable, select Item 2.

1. Requestor's Statement Regarding the Interpreter

2. Requestor's Statement Regarding the Preparer (if applicable)

Requestor's Contact Information

Requestor's Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of my records that USCIS may need to determine my eligibility for the immigration benefit I seek.

I further authorize release of information contained in this request, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administration and enforcement of U.S. immigration laws.

I certify, under penalty of perjury, that I provided or authorized all of the information in my request, I understand all of the information contained in, and submitted with, my request, and that all of this information is complete, true, and correct.

I certify that the information provided by the requestor in Part 7 applies to the household members identified in Part 3.

WARNING: If you knowingly and willfully falsify or conceal a material fact or submit a false document with your Form I-912, USCIS 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.

Requestor's Signature

Use your finger or mouse to draw your signature. You may leave it blank and sign the PDF on paper or digitally later.

NOTE TO ALL REQUESTORS: If you do not completely fill out this request or fail to submit required documents listed in the Instructions, USCIS may deny your request.

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