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I-912P, HHS Poverty Guidelines for Fee Waiver Request

Purpose of Form

This form is used as HHS Poverty Guidelines to complete Form I-912, Fee Waiver Request.

Number of Pages


Edition Date

01/28/14. Previous editions should not be used.

Where to File

This form does not need to be filed. It is used only for assistance in completing Form I-912.

Filing Fee


Special Instructions

This page can be found at

Last Reviewed/Updated: 01/28/2014