I-612 Frm Toc

TABLE OF CHANGES - FORM

Form I-612, Application for Waiver of the Foreign Residence Requirement (Under Section 212(e) of the INA, as Amended)

OMB No. 1615-0030

04/04/2017

Reason For Limited Revision: Form expiring; incorporated new language and standard language.

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1, For USCIS Use Only	For USCIS Use Only Action Block Fee Stamp Received Completed Transferred To Returned /Transferred Out Remarks	[Page 1] [no change]
Page 1,	START HERE – Type of print in black ink.	[Page 1] [no change]
Page 1-2, Part 1. Information About You	Part 1. Information About You 1. Alien Registration Number (A-Number) (if any) 2. USCIS Online Account Number (if any) Your Full Name 3.a. Family Name (Last Name) 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) 4.b. First Name (Given Name) 4.c. Middle Name 5.a. Family Name (Last Name) 5.b. First Name (Given Name) 5.c. Middle Name Your Mailing Address 6.a. Street Number and Name 6.b. Apt. Ste. Flr. 6.c. City or Town 6.d. State 6.e. ZIP Code 6.f. Province 6.g. Postal Code 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 7.d. State 7.e. ZIP Code Other Information 8. Date of Birth (mm/dd/yyyy) 9. City/Town/Village of Birth 10. Country of Birth 11. Country of Citizenship or Nationality 12. Country of Last Foreign Residence	[Page 1] Part 1. Information About You [no change] 1. [no change] 2. [no change] 3. Social Security Number (if any) [no change] 4.a. [no change] 4.b. Given Name (First Name) 4.c. [no change] Other Names Used (if any) Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 5.a. [no change] 5.b. Given Name (First Name) 5.c. [no change] 6.a. [no change] 6.b. Given Name (First Name) 6.c. [no change] [no change] 7.a. [no change] 7.b. Apt. Ste. Flr. 7.c. City or Town 7.d. State 7.e. ZIP Code 7.f. Province 7.g. Postal Code 7.h. Country If you are currently living abroad, enter your last address in the United States. 8.a. [no change] 8.b. 8.c. 8.d. 8.e. [no change] 9. Marital Status [] Single, Never Married [] Married [] Divorced [] Widowed [] Separated [] Marriage Annulled [] Other 10. [no change] 11. [no change] 12. [no change] 13. [no change] 14. [no change]
Page 2, Part 2. Reason for Foreign Residence	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. Enter the name of the U.S. Government agency or country of citizenship or nationality or last foreign residence. 3. [] 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. 4. [] 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.	[Page 2] Part 2. Reason for Foreign Residence [no change] 2.a. [] 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. 2.b. Provide the name of the U.S. Government agency or country of citizenship or nationality or last foreign residence. [no change]
Page 2-3, Part 3. Reason for Application for Waiver of Foreign Residence Requirement	I am applying for a waiver of the foreign residence requirement because (Select only one box): 1.[] My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse or children. 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. 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.) 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.a. Family Name (Last Name) 3.b. First Name (Given Name) 3.c. Middle Name 3.d. Date of Birth (mm/dd/yyyy) 3.e. Country of Birth 3.f. Country of Citizenship or Nationality 3.g. Country of Last Foreign Residence 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) 4.b. First Name (Given Name) 4.c. Middle Name 4.d. Date of Birth (mm/dd/yyyy) 4.e. Country of Birth 4.f. Country of Citizenship or Nationality 4.g. Country of Last Foreign Residence 5.a. Family Name (Last Name) 5.b. First Name (Given Name) 5.c. Middle Name 5.d. Date of Birth (mm/dd/yyyy) 5.e. Country of Birth 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 6.d. Date of Birth (mm/dd/yyyy) 6.e. Country of Birth 6.f. Country of Citizenship or Nationality 6.g. Country of Last Foreign Residence	[Page 2] Part 3. Reason for Application for Waiver of Foreign Residence Requirement [no change] [no change] [no change] IMPORTANT ADVISORY:  If you selected Part 3., Item Number 1., you must attach a statement providing a detailed explanation why you believe that your compliance with the two-year foreign residence requirement of INA section 212(e) 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 Part 3., Item Number 2., 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 What Evidence Must You Submit section of these Instructions for additional information.) [no change] Information About Spouse 3.a. [no change] 3.b. Given Name (First Name) 3.c. [no change] 4. [no change] 5. [no change] 6. [no change] 7. [no change] [no change] [no change] 8.a. [no change] 8.b. Given Name (First Name) 8.c. [no change] 9. [no change] 10. [no change] 11. [no change] 12. [no change] 13.a. [no change] 13.b. Given Name (First Name) 13.c. [no change] 14. [no change] 15. [no change] 16. [no change] 17. [no change] 18.a. [no change] 18.b. Given Name (First Name) 18.c. [no change] 19. [no change] 20. [no change] 21. [no change] 22. [no change]
Page 3-4, Part 4. Additional Information About You	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. 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 2.i. [] Other 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 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) 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. 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 U.S. citizenship of spouse or child was acquired through (Select only one box): 9.a. Birth in the United States 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. 10.a. Number of Naturalization Certificate 10.b. Date of Naturalization (mm/dd/yyyy) 10.c. Place of Naturalization City or Town 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? 11.b. If you answered “Yes” to Item Number 11.a., type or print the number of the certificate. Spouse Certificate of Citizenship Number Date of Issuance (mm/dd/yyyy) Child Certificate of Citizenship Number 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) 12.b. First Name (Given Name) 12.c. Middle Name Other Information About Lawful Permanent Spouse or Child 13. A-Number (if any) 14. Date of adjustment to lawful permanent resident status (mm/dd/yyyy) 15. Location where your spouse or children became lawful permanent residents City or Town State 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)	[Page 3] Part 4. Additional Information About You [no change] 1. Provide all exchange program numbers and names or all exchange program sponsors. Major field of activity (Select only one box): 2.a. [no change] 2.b. [no change] 2.c. [no change] 2.d. [no change] 2.e. [no change] 2.f. [no change] 2.g. [no change] 2.h. [no change] 2.i. [no change] 3. [no change] 4. Date of last entry into the United States as a J-1 participant in a designated exchange program (mm/dd/yyyy) 5. [no change] 6. [no change] 7.a. [no change] 7.b. [no change] 7.c. [no change] If you selected Part 3., Item Number 1., 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 the completion of your U.S. training and departure from the United States. [no change] 8.a. [no change] 8.b. Given Name (First Name) 8.c. [no change] [no change] 9.a. [no change] 9.b. [no change] 9.c. [no change] [no change] 10. [no change] 11. [no change] 12. [no change] [no change] 13. [no change] If you answered “Yes” to Item Number 13., provide the information for Item Numbers 14. - 17. 14. Spouse Certificate of Citizenship Number 15. Date of Issuance (mm/dd/yyyy) 16. Child Certificate of Citizenship Number 17. Date of Issuance (mm/dd/yyyy) If you answered “No” to Item Number 13., submit evidence in accordance with the What Evidence Must You Submit section of the Instructions. If you selected Part 3., Item Number 1., 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 the completion of your U.S. training and departure from the United States. [no change] 18.a. [no change] 18.b. Given Name (First Name) 18.c. [no change] Other Information About Lawful Permanent Resident Spouse or Child 19. [no change] 20. [no change] 21. [no change] 22. [no change]
Page 5, Part 5. Applicant’s Statement, Contact Information, Certification, and Signature	Part 5. Applicant’s Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form I-612 Instructions before completing this part. 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. 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. 1.b. 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. At my request, the preparer named in Part 7., __________________________, prepared this application for me based only upon information I provided or authorized. Applicant’s Contact Information 3. Applicant’s Daytime Telephone Number 4. Applicant’s Mobile Telephone Number (if any) 5. Applicant’s Email Address (if any) Applicant’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 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. Applicant’s Signature 6.a. Applicant’s Signature 6.b. Date of Signature (mm/dd/yyyy) 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.	[Page 5] Part 5. Applicant’s Statement, Contact Information, Declaration, Certification, and Signature [no change] [no change] [no change] Applicant’s Declaration and Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that U.S. Citizenship and Immigration Services (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. 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 law. I certify, under penalty of perjury, that all of the information in my application and any document submitted with it were provided or authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all of this information is complete, true, and correct. [no change] [no change]
Page 5-6, 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) Interpreter’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. 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) Interpreter’s Certification I certify, under penalty of perjury, 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. Interpreter’s Signature 7.a. Interpreter’s Signature 7.b. Date of Signature (mm/dd/yyyy)	[Page 5] Interpreter’s Contact Information, Certification, and Signature [no change] [no change] [no change] [no change] [no change] I certify, under penalty of perjury, 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 Declaration and Certification, and has verified the accuracy of every answer. [no change]
Page 6, Part 7. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	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) 2. Preparer’s Business or Organization Name (if any) Preparer’s Mailing Address 3.a. Street Number and Name 3.b. Apt. Ste. Flr. 3.c. City or Town 3.d. State 3.e. ZIP Code 3.f. Province 3.g. Postal Code 3.h. Country 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) 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. Preparer’s Certification 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 8.b. Date of Signature (mm/dd/yyyy)	[Page 6] Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant [no change] [no change] [no change] [no change] [no change] 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, you may be obliged to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, or Form G-28I, Notice of Entry of Appearance as Attorney In Matters Outside the Geographical Confines of the United States, with this application. [no change] 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 Declaration and 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. [no change] [no change] [no change]
Page 7, 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. A-Number (if any) 3.a. Page Number 3.b. Part Number 3.c. Item Number 3.d. 4.a. Page Number 4.b. Part Number 4.c. Item Number 4.d. 5.a. Page Number 5.b. Part Number 5.c. Item Number 5.d. 6.a. Page Number 6.b. Part Number 6.c. Item Number 6.d.	[Page 7] 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. Type or print 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. [no change] 1.b. Given Name (First Name) [no change] [no change] 3.a. [no change] 4.a. [no change] 5.a. [no change] 6.a. [no change] 7.a. 7.b. 7.c. 7.d.

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