Request for Fee Waiver USCIS = Form 1-912 Department of Homeland Security eon ran U.S, Citizenship and Immigration Servi apes: 10312021 Application Recelpted At (Select only one box) CJ uscls Field Oftice Cluscis serviee Center Ci Fee Waiver Approved] Fee Waiver Denied. (Fee Waiver Approved [7] Fee Waiver Denied Date, Date: Date i Date: > START HERE - Type or print in black ink. Ifyou need extra space to complete any section of this request or if you would © to provide additional information about your circumstances, use the space provided in Part 11. Additional Information. Complete and submit as many copies of Part 11,, as necessary, with your request. Select atleast one basis or more for which you may qualify and provide supporting documentation for any basis you select. You only hneéd to qualify and provide documentation for one basis for U.S. Citizenship and Immigration Services (USCIS) to grant your fee Waiver, If you choose, you may select more than one basis; you must provide supporting documentation for each basis you went considered, 1, (Xj Lam, my spouse i, or the head of household tiving in my household is currently receiving a means-tested benef, (Complete Perts 2, 4. and Parts 7, - 10.) 2, [) My household income is at or below 150 percent of the Federal Poverty Guidelines. (Complete Parts 2, -3,, Part 5.,and 7.» 10.) 3. [1] haves financial hardship, (Complete Parts 2,3. and Parts 6-10.) Provide information about yourself if you are the person requesting a fee waiver fora petition or application you are filing. Ifyou are the parent or legal guardian filing on behalf of a child or person witha physical dis Provide information about the child or person for whom you are filing this form, 1. Full Name Family Name (Last Name) Given Name (First Name) Middle Name _ ] List all other namés you have used, ineluding nicknames, aliases, and maiden name. 2. Other Names Used (if any) Family Name (Last Name) Given Name (First Name) Middle Name NIA N/A N/A NIA IN/A. N/A 3. Allen Registration Number (A-Number) (ifany) 4, USCIS Online Account Number (if any) 5. Date of Birth (mun/dd/yyyy) 6 U.S. Social Security Number (if eny) Form 1-912 10/18/19 Page tof 1Marital Status C7 Single, Never Married [XJ Married ([] Divorced [] Widowed [1 Marriage Annulled Separated pllonldns qa@Peritionedor Relationship to You | Forms Being Filed qm . eee Self IN-400 Total Number of Forms (including sel) If you selected Item Number 1. in Part 1,, complete this section 1. Ifyou, your spouse, or the head of household (including parent ifthe child is under 24 years of age) living with you is receiving any means-tested benefits, list the information inthe table below and attach supporting documentation. Ifyou are the parent or ‘egal guardian filing on behalf of a child or person with a physical disability or developmental or mental impairment, provide information about the child or person for whom you are filing this form if he or she is receiving a means-tested benefit. Full Namie of Person | Relationship | Name of Agency Typeof | Date Benefit | Date Benefit Expires Receiving the Benefit. | to You Awarding Benefit Benefit | was Awarded | (or must be renewed) eS ISSA SantaClara___[Medi-Cal___|~ 08/2019 _ Present It you selected ftem Number 2. in Part 1., complete this section 1. Eriployment Status 5 Eimployed (full-time, part-time, [] Unemployed or ([] Retired’ [1] Other (Explain) seasonal, self-employed) Not Emiployed Iva Form 912 108719 Page2 of IT2. Ifyou are currently unemployed, are you currently receiving unemployment benefits? OyYes [No ‘A. Date you became unemployed (mmidd/yyyy) vA 3. Ifyou are married or separated, does your spouse live in your household? Dyes [No A. Ifyou ansifered "No" to Item Number 3, does your spouse provide any financial support to your (yes [No househola! 4 Provide information about your income and the income of all family members counted as part of your household, You must list ell amounts in U.S, dollars. 6. ‘Are you th Jon providing the primary financial suppor for your household? Ces Ono Ifyou answered "Yes" to Item Number 4., type or print your name on the line marked "self" in the {ablé below: If you answered ‘No! to tem Number 4, type or print your name on the line marked "self in te table below aid add the head of household's ame on the life below yours as time |!S.ny income earned by this sen “pin | avon” | Mioret | FSrget | eon counted ovard ie N/A NIA Sele Olyes ()no|Ci yes O)No| Li ¥es No INIA [N/A NA, Ci¥es CNo| ives ONo| Cvs LINo N/A IN/A, N/A, O ves (No| CO) ves C)No Oyes (No N/A INA [N/A O Yes [)No| O) Yes [No Oyes (No [ Total Household Size (including self) | N/A ‘Your Annual Income SIN/IA Anni ingon4t All Fenty Members Provide the annual income of all family members counted as part of your household as listed in Item Number 4, (Do not include te anoint pve inten Nusier 8) SRA Total Additional Income or Financial Support SIN/A Provide the total annual amount you receive in addtional income or financial support from a source outside of yout household (Do not include the amount provided in Item Numbers 5. or 6.) You must adé all ofthe addtional income and financial support ‘amounts and plit the total amount in the space provided. Type or print "0" in the total box if there are none. Select the type of additional income or financial support that you receive and provide documentation, C Parental Support (J Educational Stipends [7] Unemployment Benefits [[] Financial Support From Adult Children, 1 spouse! SujprtcAtinony) [5 Royaties soci security Benesis Dependents, Other People Living inthe CT Child Support Oi Pensions (Cl Veteran's Benefits Other (Explain) | IN/A Form 912 1ostg ‘Page 3 of 11file reder Ahoy cre @uidel 8, Total Household Income (add the amounts from Item Numbers 5, 6., and 7:) SIN/A Has anything changed since the date you filed your Federal tax returms?. (For example, your marital status, [] Yes [] No income, or number of dependents.) Ifyou answered "Yes" to Item Number 9., provide an explanation below. Provide documentation if available. You may also use this bpace to provide any additional information about your circumstances that you would like USCIS to consider NA Ifyou selected Item Number 3, in Part 1., complete this sect Ifyou or any family members have a situation that has caused you to incur expenses, debts, or loss of income, describe the situation in the box below. Specify the amounts of the expenses, debts, and income losses in as much detail as possibe. Examples may include medical expenses, Job loss, eviction, and homelessness, NA Ifyou have cash or assets that you can quickly convert to cash, list those inthe table below. For example, bank accounts, stocks, or bonds. (Do not include retirement accounts.) ‘Type of Asset Value (US. Dollars) NAL INA N/A IN N/A INA Total Value of Assets [ya Fonn 912. 10/18/19 Page of 113. Total Monthly Expenses and Liabilities SNA Provide the total monthly amount of your expenses and liabilities. You must add all ofthe expense and liability amounts and type Or print the total amount in the space provided. Type or print 0” in the total box if there are none, Select the types of expenses or liabilities you have each month and provide evidence of monthly payments, where possible. Ci Rent and/or Mortgage [] Loans and/or Credit Cards. ([] Other C1 Foo CO carPayment NA O Utilities 2 Commuting Costs 1 Child andor Eider Core [] Medical Expenies 1 Insurance 1 School Expenses “ Wiiurnet on Geruueanbnenne sienuuune NOTE: Read the Penalties section of the Form I-912 Instructions before completing this part Each perton applying for a fee waiver request must complete, sign, and date Form I-912 and provide the required documentation. This includes family members identified in Part 3. Signature fields for family members are atthe end ofthis part. If an individual is under 14 years of age, a parent or legal guardian may sign the request on their behalf, USCIS rejects any Form I-912 tha isnot signed by all individuals requesting a fee waiver and may deny a request that does not provide required documentation, Select the box for either Item A. or B. in Item Number 1, Ifapplicable, select the box for Item Number 2. 1, Requestor’ Statement Regarding the Interpreter ‘A. [J Ican read and understand English, and J have read and understand every question and instruction on this request and my answer to every question. B. [1] Tho interpreternamed in Part 9, read to me every question and instruction on this request and my answer to every question in V/A |, language in which Iam fluent, and I understood every 2, Requestor’ Statement Regarding the Preparer (if applicable) Atmyrequest ine preparer nared in Port 10, oT | Prepared this request for me based only upon information provided OF ahorized, 3. Requestor’s Daytime Telephone Number 4. Requestor’s Mobile Telephone Number (if any) meme] [NVA 8. a Email Address a 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, | authorize the release of any information from any of ‘my records that USCIS may need to determine my eligibility forthe immigration benefit I seek. | further authorize release of information contained in this request, in supporting documents, and in my USCIS records to other entities and persons where necessaty for the administration and enforcement of U.S. immigration laws. | certify, under penalty of perjury, that I provided or authorized all ofthe information in my request, | understand al ofthe information contained in, and submitted wit, my request, and that all ofthis information is complete, true, and corvet Form F912 10/15/19 Page Sof 11MERU Contaei ln tinnialoHmecrats WARNING: If you knowingly and willfully falsity or conceal a material fact or submit a false document with your Form 1-912, USCIS will deny your fee waiver request and may deny eny other immigration benefit. In addition, you may face severe penalties Provided by law and may be subject to eriminal prosecution. 6 Regues Signature Date of Signature (mm/dd/yyyy) or [o3f\Jre2) J NOTB.TO ALL REQUESTORS: If you do not completely fill out this request or fil to submit required documents listed in the Instructions, USCIS may deny your request NOTE: Each family member must type or pint their fll name and signin the spaces below. You can find aditional family ‘iembets' signature spaces in Item’‘Numbers 7.- 10. below. All family members identified in Part 3, must sign and date Form 1-912. | certify that the information provided by the requestor in Part 7, applies to me. 7. Family Member 1 Family Member's Name Family Member's Signature Date of Signature (mmidd/yyyy) l J Family Member 2 Fear Member's Name Family Member's Signature Date of Signature (mm/dd/yy) 9. Family Member 3 Family Member's Name Family Members Signature Date of Signature (mm/dd/yy) 10," Paty Meier + Family Member's Name emily Member's Signature Dae of Satur (aly) 11, Family Member 5 Famlly Members Name Family Members Signature Date of Signature (mmiddiyyyy) 1 Fommi-912 10/5719 Page 6 0f 11NOTE: Read the Penalties section of the Form I-912 Instructions before completing this par. {the information provided by the requestor in Part 7, isnot applicable to family member identified in Part 3, (for example, the family member used an interpreter or speaks a different language) that individual should complete Part 8. USCIS relects any Form 1-912 that isnot signed by all individuals requesting a fee waiver, Select the box for either Item A. or B, in Item Number 1, If applicable, select the box for Item Number 2, 1, Family Member's Statement Regarding the Interpreter for [N/A Av O] Iean bf dnd bnderstand English, and I have réad and understand every question and instruction on this request and my answer to every question B. [7] The interpréter named in Part 9. read to me every question and instruction on this request and my answer fo every question in [N/A a language in which am fluent, and | understood everything, 2, Family Member's Statement Regarding the Preparer for [NIA (C) Atmy request, the preparer named in Part 10, : prepared this request for me based only upon informalfon I provided or authorized, 3. Family Member's Daytime Telephone Number 4, Family Member's Mobile Telephone Number (if any) [N/A [wa 8. Family Member's Email Address (if any) N/A, Copies of any documents 1 have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that {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, | 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. T certify, under penalty of perjury, that! provided or authorized all ofthe information in my request, understand all ofthe information contained in, and submitted with, my request, and that all ofthis information is complete, true, and correct, 6. Family Metbers Signature Date of Signature (mm/dd/yyyy) [N/a [Na NOTE TO ALL FAMILY MEMBERS: if you do not completely fill out this request or fail to submit required documents listed in the Instructions, USCIS may deny your request. Form 1-912 10/13/19 Page 7of 111. Did any person filing this request use an interpreter? Yes, (complete this section) [3] No skip to Part 10) 2, Was the same interpreter used for all individuals requesting a fee waiver (as listed in Part 3.)? Clyes O no NOTE for Family Members:. If you used a different interpreter than the one used by the requestor, make additional copies of Part 9,, provide the following information, indicate the family member for whom he or she interpreted, and include the pages with your ‘completed Form 1-912, Provide the following information about the interpreter for [N/A 3. Intenpreter's Family Name (Last Name) Interpreters Given Name (First Namo) [N/A [iA Interpreter's Business or Organization Name (if any) vA 5. Street Number and Name Apt. Ste. Flr, Number [N‘A Oo -OWNA City or Town. State ZIP Code N/A VA VA Province Postal Code Country INA [N/A [wa 6. Interpreters Daytime Telephone Number 7. Interpreters Mobile Telephone Number (i'any) [Nia UA 8. Inerpreter's Email Address (if any) INA | cently, under penalty of perjury, that: {at fluent in English and [N/A |, which is the same language specified in Part 7, Item B, in Item Number T, and have read@o this requestor ta Wie Wanted ngage every question and instruction on this request and his or her answer to every question, The requestor informed me that he or she understands every instruction, question, and answer on the request, including the Applicant's Certification, and has verified the accuracy of every answer. 9, Interpreters Signature Date of Signature (mmidd/yyyy) [NA WA Form L912 10/15/19 Page 8 of 111, Did any persori prepare this request of your behalf? (Yes, (complete this section) C] No, skip 2. Was the same preparer used forall individuals requesting a fee waiver (as listed in Part 3)? OD Yes 1 No NOTE for Family Members: If you used aisferent preparer then the one used by the requestor, provide the following information, and include the pages with your completed Form I-912, Provide the following information about the preparer for ) 3. Preparer’s Family Name (Last Name) Preparer's Given Name (First Name) 4. Prepares Business or Organization Name (if any) Pars Equality Center S. Street Number and Name ‘Apt. Ste, Flr, Number 1635 The Alameda OO wp City or Town, State ZIP Code [San Jose (ca ]psize Province Postal Code Country ] [United States 6. Preparers Daytime Telephone Number Preparers Mobile Telephone Number (if any) [408-261-640 [va 8. Preparer's Email Address (if any) (ei op arsequalitycenter.org A. [1] Lam not an ettomey of accredited representative but have prepared this request on behalf ofthe requestor and withthe requesto's consent. B. [X] 1am an atiomey or accredited representative and my representation ofthe requestor in this case Clextends (Xj doesnot extend beyond the preparation ofthis request. NOTE: If you are an attorney or accredited representative, you may be obliged to submit a completed Form 6-28, Notice of Entry of Appearance ts Attamey or Accredited Representative, oF-G-281, Notice of Entry of Appearaice as Attorney In Matters Outside the Geo graphical Confines ofthe United States, wth this request, Form 912. 10/13/19 Page 90f 1By my signature, 1 certify, under penalty of perjury, that 1 prepared this request atthe request of the requestor. The requestor then reviewed this completed request and informed me th ‘at he or she understands all of the information contained in, and submitted with, his or her request, including the Applleants Certification, and tat all of this infomation is complet, tu, and correct. I completed this request based only on information that the requestor provided to me of authoriged me to obtain or use, 10, Preparers SI ‘a Date of Si 03/O\fzce) a : ) Form |-912 1015/9, Page 10 of tT{f you need extra space to provide any additional information within this request, use the space below. Ifyou need more space then ‘what is provided, you may make copies of this page to complete and file with this request or attach a separate sheet of peper. Include 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, 1, Family Name (Last Name) Given Name (First Name) Middle Name vA 2. ANumber (ifany) A. ‘AL Page Number B. Part Numb C..Item Number vA [NA VA > NA 4. A, PageNumber___B, Part Number___C, [tem Number [N/A IAL [NYA > NIA 5. A. Page Number B. Part Number, tem Number [Na [Nv vA DNA 6 A. Page Number B, Part Number C._ ‘tem Number _ vA pyva wa > NVA Form i-912 10/13/19 Page 11 of 1COUNTY OF SANTA CLARA Soci SentoosAzency VERIFICATION OF RECEIPT OF MEDI-CAL e oA Verma Cas0Nene TS CosoNunde: SR cu susqye’ — WorkerNama: Benefits Service Ctr Worker Number: A7NT San Jose CA 95136-4143 Worker Telephone: (408) 758-3600 ate o2ior2021 This is to verify TES currently receiving Medi-Cal. HisiHer share of cost is $0.00 per month, ‘TSC6E- VERIFICATION OF RECEIPT OF MEDICAL PAGE TOFT