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

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

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

2.

USCIS Online 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 06/22/2015 N

Page 1 of 7

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):

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.

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

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.)
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 06/22/2015 N

Country of Citizenship or Nationality

Page 2 of 7

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

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4.b. First Name (Given Name)

Part 4. Additional Information About You

4.c. Middle Name

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 06/22/2015 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 7

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

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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.
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)

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

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 06/22/2015 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

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Part 5. Applicant's Statement, Contact
Information, Certification, and Signature

Applicant's Signature
6.a. Applicant's Signature

NOTE: Read the Penalties section of the Form I-612
Instructions before completing this part.

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

Applicant's Statement
NOTE: 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.

I can read and understand English, and I have read
and understand every question and instruction on this
application and my answer to every question.

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The interpreter named in Part 6. read to me every
question and instruction on this application and my
answer to every question in
a language in which I am fluent, and I understood
everything.

2.

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.

Provide the following information about the interpreter.

,

Interpreter's Full Name

1.a. Interpreter's Family Name (Last Name)

At my request, the preparer named in Part 7.,

prepared this application for me based only upon
information I provided or authorized.

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

,

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

Interpreter's Business or Organization Name (if any)

Applicant's Contact Information
3.
4.

Applicant's Daytime Telephone Number

Interpreter's Mailing Address

Applicant's Mobile Telephone Number (if any)

3.a. Street Number
and Name
3.b.

5.

Applicant's Email Address (if any)

Apt.

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
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 I provided or authorized
all of the information in my application, I understand all of the
information contained in, and submitted with, my application,
and that all of this information is complete, true, and correct.

Form I-612 06/22/2015 N

Flr.

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

Applicant's Certification

Ste.

3.f.

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Mobile Telephone Number (if any)

6.

Interpreter's Email Address (if any)

Page 5 of 7

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

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

5.

Preparer's Mobile Telephone Number (if any)

6.

Preparer's Email Address (if any)

Interpreter's Certification
I certify that:
I am fluent in English and

,

which is the same language specified in Part 5., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
she understands every instruction, question, and answer on the
application, including the Applicant's Certification, and has
verified the accuracy of every answer.

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Preparer's Statement

7.a.

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

7.b.

I am an attorney or accredited representative and
have prepared this form on behalf of the authorized
individual and with the authorized individual's
consent.

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

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

Preparer's Certification

Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Provide the following information about the preparer.

Preparer's Full Name

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

By my signature, I certify, under penalty of perjury, that I
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and informed
me that he or she understands all of the information contained in,
and submitted with, his or her application, including the
Applicant's Certification, and that all of this information is
complete, true, and correct. I completed this application based
only on information that the applicant provided to me or
authorized me to obtain or use.

Preparer's Signature

8.a. Preparer's Signature

2.

Preparer's Business or Organization Name (if any)

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

Preparer's Mailing Address
3.a. Street Number
and Name
3.b.

Apt.

Ste.

Flr.

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

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-612 06/22/2015 N

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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.
1.a

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

5.b. Part Number

5.c. Item Number

5.d.

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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.b. Part Number

4.c. Item Number

4.d.

Form I-612 06/22/2015 N

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