Form I-612 Form I-612 Application for Waiver of the Foreign Residence Requirem

Application for Waiver of the Foreign Residence Requirement
(Under Section 212(e) of the INA, as Amended)
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-612

OMB No. 1615-0030
Expires 03/31/2017

For USCIS Use Only
Action Block

Fee Stamp

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Completed

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Remarks

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► START HERE - Type or print in black ink.

Part 1. Information About You
1.

Alien Registration Number (A-Number) (if any)
► A-

2.

USCIS ELIS Account Number (if any)
►

Your Full Name

3.a. Family Name (Last Name)

Your Mailing Address

6.a. Street Number
and Name
6.b.

Apt.

Ste.

Flr.

6.c. City or Town
6.d. State
6.f.

6.e. ZIP Code

Province

6.g. Postal Code

3.b. First Name (Given Name)
3.c. Middle Name

Provide other names you have used, including maiden name,
aliases, and tribal names.
4.a. Family Name (Last Name)

6.h. Country

If you are currently living abroad, enter your last address in
the United States.
7.a. Street Number
and Name
7.b.

Apt.

Ste.

Flr.

7.c. City or Town

4.b. First Name (Given Name)

7.d. State

4.c. Middle Name

Other Information

7.e. ZIP Code

8.

Date of Birth (mm/dd/yyyy)

5.a. Family Name (Last Name)

9.

City/Town/Village of Birth

5.b. First Name (Given Name)

10.

Country of Birth

5.c. Middle Name

11.

Country of Citizenship or Nationality

Form I-612 03/12/2015 N

Page 1 of 8

Part 1. Information About You (continued)
12.

Country of Last Foreign Residence

Part 2. Reason for Foreign Residence
Requirement
I believe I am subject to the foreign residence requirement
because (Select all applicable boxes):
1.

I participated in an exchange program that was
financed by an agency of the U.S. Government or the
government of my country of citizenship or nationality
or last foreign residence, for the purpose of promoting
international education and cultural exchange.

2.

An agency of the U.S. Government or the government
of my country of citizenship or nationality or last
foreign residence gave me a grant (such as a Fulbright
grant), stipend, or allowance for the purpose of
participating in an exchange program.

IMPORTANT ADVISORY: If you selected Item Number 1.
in Part 3., you must attach a statement providing a detailed
explanation why you believe that your compliance with the
two-year foreign residence requirement of section 212(e) of
the Immigration and Nationality Act (INA) would impose
exceptional hardship on your U.S. citizen or lawful permanent
resident spouse or children. You must also sign and date the
statement. If you do not include this statement, your application
is incomplete. In your statement, you must also include all
pertinent financial information regarding your and your spouse's
income and savings. You must also attach any available
evidence that supports your claims of hardship.
If you selected Item Number 2. in Part 3., you must attach a
statement that details the reasons why you believe you cannot
return to your country of citizenship or nationality or last
foreign residence because you would be subject to persecution
on account of race, religion, or political opinion. You must also
sign and date the statement and attach any available evidence
that supports your claims of persecution. (See the General
Requirements section of the Instructions for additional
information.)

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Enter the name of the U.S. Government agency or
country of citizenship or nationality or last foreign
residence

List all J-2 dependents that are included in this application. If
you need extra space to complete this section, use the space
provided in Part 8. Additional Information.

Information About Spouse

3.

4.

I became an exchange visitor after the U.S. Secretary
of State designated my country of citizenship or
nationality or last foreign residence as clearly requiring
the services of persons with my specialized knowledge
or skill.
I entered the United States as, or my status was
changed to, an exchange visitor on or after
January 10, 1977, to participate in graduate medical
education or training.

3.a. Family Name (Last Name)
3.b. First Name (Given Name)
3.c. Middle Name

3.d. Date of Birth (mm/dd/yyyy)

Part 3. Reason for Application for Waiver of
Foreign Residence Requirement

3.e. Country of Birth

I am applying for a waiver of the foreign residence requirement
because (Select only one box):

3.f.

1.

My departure from the United States would impose
exceptional hardship on my U.S. citizen or lawful
permanent resident spouse or children.

3.g. Country of Last Foreign Residence

2.

I cannot return to my country of citizenship or
nationality or last foreign residence because I would
be subjected to persecution on account of race,
religion, or political opinion.

Form I-612 03/12/2015 N

Country of Citizenship or Nationality

Page 2 of 8

Part 3. Reason for Application for Waiver of
Foreign Residence Requirement (continued)

6.d. Date of Birth (mm/dd/yyyy)
6.e. Country of Birth

Information About Children
If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
4.a. Family Name (Last Name)

6.f.

Country of Citizenship or Nationality

6.g. Country of Last Foreign Residence

4.b. First Name (Given Name)

Part 4. Additional Information About You
4.c. Middle Name

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4.d. Date of Birth (mm/dd/yyyy)
4.e. Country of Birth
4.f.

If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
1.

List all exchange program numbers and names or all
exchange program sponsors.

Country of Citizenship or Nationality

4.g. Country of Last Foreign Residence

Major field of activity (Select only one box):
2.a.

Agriculture

2.b.

Business Administration

2.c.

Education

2.d.

Engineering

2.e.

Humanities

2.f.

Medicine

2.g.

Natural and Physical Sciences

2.h.

Social Sciences

5.d. Date of Birth (mm/dd/yyyy)

2.i.

Other

5.e. Country of Birth

3.

Occupation

4.

Date of last entry into the United States as a participant in
a designated exchange program (mm/dd/yyyy)

5.

Port-of-Entry (POE) of last arrival in the United States as
a participant in a designated exchange program

5.a. Family Name (Last Name)
5.b. First Name (Given Name)
5.c. Middle Name

5.f.

Country of Citizenship or Nationality

5.g. Country of Last Foreign Residence

6.a. Family Name (Last Name)
6.b. First Name (Given Name)
6.c. Middle Name

Form I-612 03/12/2015 N

City or Town
State
6.

If you are now abroad, provide the date of your most
recent departure from the United States (mm/dd/yyyy)

Page 3 of 8

11.b. If you answered “Yes” to Item Number 11.a., type or
print the number of the certificate.

Part 4. Additional Information About You
(continued)

Spouse Certificate of Citizenship Number

If you are married, select only one box.
7.a.

My spouse is included in this application.

7.b.

My spouse is filing a separate application for a
waiver of the foreign residence requirement.

7.c.

My spouse is not included in this application.

Date of Issuance (mm/dd/yyyy)
Child Certificate of Citizenship Number

If you selected Item Number 1. in Part 3., provide the
following information about your U.S. citizen spouse or
children who you believe would suffer exceptional hardship if
you resided outside of the United States for two years following
your departure from the United States.

11.c. If you answered “No” to Item Number 11.a., submit
evidence in accordance with the “General
Requirements” section of the Instructions.

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Name of the U.S. citizen spouse or child:
8.a. Family Name (Last Name)
8.b. First Name (Given Name)
8.c. Middle Name

Date of Issuance (mm/dd/yyyy)

If you selected Item Number 1. in Part 3., and you do not have
a U.S. citizen spouse or child but you have a spouse or child
who is a lawful permanent resident (LPR) of the United States,
please provide the following information about your LPR
spouse or child who you believe would suffer exceptional
hardship if you resided outside of the United States for two
years following your departure from the United States.
Name of the lawful permanent resident spouse or child:
12.a. Family Name (Last Name)

U.S. citizenship of spouse or child was acquired through
(Select only one box):

12.b. First Name (Given Name)

9.a.

Birth in the United States

12.c. Middle Name

9.b.

Naturalization

9.c.

Parents

If your spouse or child acquired U.S. citizenship through
naturalization, provide the following information for each
naturalized individual.

Other Information About Lawful Permanent
Spouse or Child

13.

A-Number (if any)

► A-

10.a. Number of Naturalization Certificate

14.

Date of adjustment to lawful permanent resident status
(mm/dd/yyyy)

15.

Location where your spouse or children became lawful
permanent residents

10.b. Date of Naturalization (mm/dd/yyyy)
10.c. Place of Naturalization

City or Town

City or Town

State

State
If your spouse or child acquired U.S. citizenship through
parents, provide the following information for your spouse
and each child who obtained citizenship through parents.
11.a. Has your spouse or child obtained a Certificate of
Citizenship?
Yes

Form I-612 03/12/2015 N

16.

Basis (preference category) for adjusting to lawful
permanent resident status (for example, F-2A, Spouse or
unmarried child of an LPR; F-2B, Unmarried sons or
daughters of an LPR)

No

Page 4 of 8

Applicant's Contact Information

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature
NOTE: Read the information on penalties in the Penalties
section of the Form I-612 Instructions before completing this
part.

3.

Applicant's Daytime Telephone Number

4.

Applicant's Mobile Telephone Number (if any)

5.

Applicant's Email Address (if any)

Applicant's Statement
Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
1.a.

1.b.

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I can read and understand English, and have read and
understand every question and instruction on this
application, as well as my answer to every question.
I have read and understand the Acknowledgement of
Appointment at USCIS Application Support
Center.

The interpreter named in Part 6. has read to me every
question and instruction on this application, as well
as my answer to each question, in
,
a language in which I am fluent. I understand every
question and instruction on this application as
translated to me by my interpreter, and have provided
complete, true, and correct responses in the language
indicated above. The interpreter named in Part 6.
has also read the Acknowledgement of
Appointment at USCIS Application Support
Center to me, in the language in which I am fluent,
and I understand this Application Support Center
(ASC) Acknowledgement as read to me by my
interpreter.

2.

Acknowledgement of Appointment at USCIS
Application Support Center

I have requested the services of and consented to

is
is not an attorney or accredited
who
representative, preparing this application for me.
This person who assisted me in preparing my
application has reviewed the Acknowledgement of
Appointment at USCIS Application Support
Center with me, and I understand the ASC
Acknowledgement.

Form I-612 03/12/2015 N

,

I,

,

understand that the purpose of a USCIS ASC appointment is for
me to provide my fingerprints, photograph, and/or signature and
to re-affirm that all of the information in my application is
complete, true, and correct and was provided by me. I
understand that I will sign my name to the following declaration
which USCIS will display to me at the time I provide my
fingerprints, photograph, and/or signature during my ASC
appointment:
By signing here, I declare under penalty of perjury that I
have reviewed and understand my application, petition, or
request as identified by the receipt number displayed on
the screen above, and all supporting documents,
applications, petitions, or requests filed with my
application, petition, or request that I (or my attorney or
accredited representative) filed with USCIS, and that all of
the information in these materials is complete, true, and
correct.

I also understand that when I sign my name, provide my
fingerprints, and am photographed at the USCIS ASC, I will be
re-affirming that I willingly submit this application; I have
reviewed the contents of this application; all of the information
in my application were provided by me and all supporting
documents submitted with my application are complete, true,
and correct; and if I was assisted in completing this application,
the person assisting me also reviewed this Acknowledgement
of Appointment at USCIS Application Support Center with
me.

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Interpreter's Mailing Address

Part 5. Applicant's Statement, Contact
Information, Acknowledgement of Appointment
at USCIS Application Support Center,
Certification, and Signature (continued)

3.a. Street Number
and Name

Applicant's Certification

3.c. City or Town

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 and all of my records that USCIS
may need to determine my eligibility for the immigration
benefit that I seek.

3.d. State

3.b.

3.f.

Apt.

Ste.

Flr.

3.e. ZIP Code

Province

3.g. Postal Code

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I furthermore authorize release of information contained in this
application, 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 under the laws of the
United States of America, that the information in my
application and any document submitted with my application
were provided by me and are complete, true, and correct.

Applicant's Signature

6.a. Applicant's Signature

3.h. Country

Interpreter's Contact Information

4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Interpreter's Certification

I certify that:

6.b. Date of Signature (mm/dd/yyyy)

I am fluent in English and
, which
is the same language provided in Part 5., Item Number 1.b.;

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

I have read to this applicant every question and instruction on this
application, as well as the answer to every question, in the
language provided in Part 5., Item Number 1.b.;

Part 6. Interpreter's Contact Information,
Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)
1.b. Interpreter's Given Name (First Name)
2.

Interpreter's Business or Organization Name (if any)

I have read the Acknowledgement of Appointment at USCIS
Application Support Center to the applicant in the same
language provided in Part 5., Item Number 1.b.
The applicant has informed me that he or she understands every
instruction and question on the application, as well as the answer
to every question, and the applicant verified the accuracy of
every answer; and

The applicant has also informed me that he or she understands
the ASC Acknowledgement and that by appearing for a USCIS
ASC biometric services appointment and providing his or her
fingerprints, photograph, and/or signature, he or she is
re-affirming that the contents of this application and all
supporting documentation are complete, true, and correct.

Interpreter's Signature
6.a. Interpreter's Signature

6.b. Date of Signature (mm/dd/yyyy)

Form I-612 03/12/2015 N

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Part 7. Contact Information, Statement,
Certification, and Signature of the Person
Preparing this Application, If Other Than the
Applicant
Provide the following information concerning the preparer.

Preparer's Full Name
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
2.

Preparer's Mailing Address

3.b.

Apt.

3.c. City or Town
3.d. State
3.f.

Province

3.g. Postal Code
3.h. Country

7.a.

I am not an attorney or accredited representative but
have prepared this application on behalf of the
applicant and with the applicant's consent.

7.b.

I am an attorney or accredited representative and my
representation of the applicant in this case
extends
does not extend beyond the
preparation of this application.

NOTE: If you are an attorney or accredited representative
whose representation extends beyond preparation of this
application you must submit a completed Form G-28, Notice of
Entry of Appearance as Attorney or Accredited Representative,
with this application.

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Preparer's Business or Organization Name (if any)

3.a. Street Number
and Name

Preparer's Statement

Ste.

Flr.

3.e. ZIP Code

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Fax Number

6.

Preparer's Email Address (if any)

Form I-612 03/12/2015 N

Preparer's Certification

By my signature, I certify, swear, or affirm, under penalty of
perjury, that I prepared this application on behalf of, at the
request of, and with the express consent of the applicant. I
completed this application based only on responses the applicant
provided to me. After completing the application, I reviewed it
and all of the applicant's responses with the applicant, who
agreed with every answer on the application. If the applicant
supplied additional information concerning a question on the
application, I recorded it on the application. I have also read the
Acknowledgement of Appointment at USCIS Application
Support Center to the applicant and the applicant has informed
me that he or she understands the ASC Acknowledgement.

Preparer's Signature

8.a. Preparer's Signature

8.b. Date of Signature (mm/dd/yyyy)

Page 7 of 8

5.a. Page Number

Part 8. Additional Information
If you need extra space to provide any additional information
within this application, use the space below. If you need more
space than what is provided, you may make copies of this page
to complete and file with this application or attach a separate
sheet of paper. 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; and sign and
date each sheet.

5.b. Part Number

5.c. Item Number

5.d.

1.a

Family Name
(Last Name)
1.b. First Name
(Given Name)
1.c. Middle Name
2.

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A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

6.a. Page Number

3.d.

6.b. Part Number

6.c. Item Number

6.d.

4.a. Page Number

4.d.

4.b. Part Number

4.c. Item Number

7.a. Applicant's Signature

7.b. Date of Signature (mm/dd/yyyy)

Form I-612 03/12/2015 N

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