I-612 Pta

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
[email protected]
Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.

Privacy Threshold Analysis – IC/Form

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms. This
specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this PTA
to assess internal, component-specific forms as well.
Form Number:
Form Title:

I-612
Application for Waiver of the Foreign Residence Requirement (Under
Section 212(e) of the INA, as Amended)
U.S. Citizenship and
Office:
Service Center
Immigration Services
Operations
(USCIS)

Component:

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
Click here to enter text.
OMB Control
Number:
Collection status:

Name:
Office:
Phone:

Name:

1615-0030
Revision

OMB Expiration
Date:
Date of last PTA (if
applicable):

March 31, 2017
September 17,
2013

PROJECT OR PROGRAM MANAGER
Angela Lyons
SCOPS
Title:
Adjudications Officer
202.272.1585
Email:
[email protected]
v
COMPONENT INFORMATION COLLECTION/FORMS CONTACT
John Ramsay

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Office:
Phone:

PRA Compliance

Title:

PRA Project Compliance
Manager
202.272.8664
Email:
[email protected]
ov
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
The Form I-612, Application for Waiver of the Foreign Residence Requirement (Under
Section 212(e) of the INA, as Amended) (OMB No. 1615-0030) expires March 31, 2017
and is scheduled to undergo an Information Collection Revision. The form and
instructions are scheduled for non-substantive plain language updates to include
Standard Language required by Office of Management and Budget (OMB). USCIS
continues to use the USCIS ELIS Account Number to verify whether the applicant has an
existing USCIS ELIS account.
To be eligible to apply for an immigrant visa or for lawful permanent residence in the
United States, certain J-1 and J-2 exchange visitors must reside and be physically present
in the country of their citizenship or nationality or last foreign residence for at least two
years following departure from the United States. Form I-612 provides eligible J-1 and J2 visa holders the opportunity to apply for a waiver of this requirement.
PII collected from the applicant and the applicant’s spouse and or children includes:
name; date of birth; mailing address; telephone number; e-mail address; zip code;
mother’s maiden name; A number; country of citizenship or nationality; country of last
foreign residence; naturalization certificate number; alias(es); if living abroad, last
address in the U.S.; Place of Birth; marital status; exchange program information;
occupation; arrival/departure information; signature . The information is used to
accurately identify the applicant so we can review the applicant’s status, to confirm that
the applicant is subject to the 2 year foreign residency requirement, and to verify that the
applicant’s spouse and or child is a LPR/USC as the waiver’s qualifying extreme hardship
is to the applicant’s LPR/USC spouse or child.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Preparer PII includes: name, address, phone number, email address, business or
organization name, and signature.
Interpreter PII includes: name, address, phone number, email address, business or
organization name, and signature.
b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
Section 212€ of the INA, as Amended.

2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII1)?
b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

c. Who will complete and
submit this form? (Check
all that apply.)

☒ Yes
☐ No
☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☒ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.
☒ The record subject of the form (e.g., the
individual applicant).
☒ Legal Representative (preparer, attorney,
etc.).
☐ Business entity.
If a business entity, is the only
information collected business contact
information?
☐ Yes
☐ No
☐ Law enforcement.

1

Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including
any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident,
visitor to the U.S., or employee or contractor to the Department.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

☐ DHS employee or contractor.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.
d. How do individuals
complete the form? Check
all that apply.

☐ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:
e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
The current version of Form I-612 asks for:

a. Name of lawful permanent resident alien spouse or child
b. Alien Registration Number (A-Number)
c. Date of adjustment to lawful permanent resident (mm/dd/yyyy)
d. Location where your spouse or child became a lawful permanent resident
e. Basis (preference category) for adjusting to lawful permanent resident
PII collected from the applicant and the applicant’s spouse and or children includes:
name; date of birth; mailing address; telephone number; e-mail address; zip code;
mother’s maiden name; A number; country of citizenship or nationality; country of last
foreign residence; naturalization certificate number; alias(es); if living abroad, last
address in the U.S.; Place of Birth; marital status; exchange program information;
occupation; arrival/departure information; signature . The information is used to
accurately identify the applicant so we can review the applicant’s status, to confirm that
the applicant is subject to the 2 year foreign residency requirement, and to verify that the
applicant’s spouse and or child is a LPR/USC as the waiver’s qualifying extreme hardship
is to the applicant’s LPR/USC spouse or child.
Interpreter PII includes: name, address, phone number, email address, business or
organization name, and signature.
Preparer PII includes: name, address, phone number, email address, business or
organization name, and signature.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.
☐ Social Security number
☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☒ Alien Number (A-Number)
☐ Social Media Handle/ID
☐ Tax Identification Number
☐ Known Traveler Number
☐ Visa Number
☐ Trusted Traveler Number (Global
☐ Passport Number
Entry, Pre-Check, etc.)
☐ Bank Account, Credit Card, or other
☐ Driver’s License Number
financial account number
☒ Biometrics, if required. (signature)
X Other. Please list:
USCIS Online Account Number
g. List the specific authority to collect SSN or these other SPII elements.
INA 264(f) (8 U.S.C. 1304(f)) provides the Secretary of Homeland Security with the specific authority
to collect information from those applying for immigration benefits.

h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
USCIS personnel conduct background security checks on applicants for the purpose of determining
whether the applicant has established eligibility for the benefit requested. Because the I-612 is typically
a non-interview, paper-based adjudication, the data collected is especially useful and provides
significant information to verify an applicant’s identity and his/her claim to eligibility: providing a
critical tool for more accurate and appropriate adjudication determinations for USCIS and the
applicant.

i.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of
the collection or is

Privacy Threshold Analysis – IC/Form

☒ Yes. Please describe how notice is provided.
A Privacy Act Statement is provided on the form
instructions.
☐ No.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

form filled out by
third party)?

3. How will DHS store the IC/form responses?
a. How will DHS store
☐ Paper. Please describe.
the original,
Click here to enter text.
completed IC/forms?
☒ Electronic. Please describe the IT system that will
store the data from the form.
CLAIMS 3
☐ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
Click here to enter text.
b. If electronic, how
does DHS input the
responses into the IT
system?

☒ Manually (data elements manually entered). Please
describe. Data elements required are prompted by the
CLAIMS receipting screen for the specific
application/petition type. Relating files, such as family
members or group members, are bundled together.
CLAIMS will automatically search for and request any
existing file on the applicant. Cases not requiring a new or
requested "A" file are forwarded prior to adjudication
immediately after data entry.

☐ Automatically. Please describe.

c. How would a user
search the
information
submitted on the
forms, i.e., how is the

☒ By a unique identifier.2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Records retrieved by name, A number, date and
country of birth

2

Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

information
retrieved?

☐ By a non-personal identifier. Please describe.
Click here to enter text.
Five years. The record schedule number is N1-85-96-01

d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
The Form is processed in CLAIMS 3. The form is not
typically added to an A file. The form is typically sent for
that records are
disposed of or deleted short term storage at Harrisonburg and then destroyed
after its retention period is over.
in accordance with
the retention
schedule?
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
☒ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Form I-612 applications filed overseas are accessible to Department of State consular
Officers.

☐ No. Information on this form is not shared outside of the collecting office.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Kim Mott

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:

March 8, 2017

Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component Privacy
Act Statements.)

Click here to enter a date.
☐ Yes. Please include it with this PTA
submission.
USCIS Office of Privacy developed a Privacy Act
Statement and is seeking program and OCC
approval.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The Form I-612, Application for Waiver of the Foreign Residence Requirement (Under
Section 212(e) of the INA, as Amended) (OMB No. 1615-0030) expires March 31, 2017 and
is scheduled to undergo an Information Collection Revision. The form and instructions are
scheduled for non-substantive plain language updates to include Standard Language
required by Office of Management and Budget (OMB). USCIS continues to use the USCIS
ELIS Account Number to verify whether the applicant has an existing USCIS ELIS account.
To be eligible to apply for an immigrant visa or for lawful permanent residence in the
United States, certain J-1 and J-2 exchange visitors must reside and be physically present in
the country of their citizenship or nationality or last foreign residence for at least two years
following departure from the United States. Form I-612 provides eligible J-1 and J-2 visa
holders the opportunity to apply for a waiver of this requirement.

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Version number: 04-2016

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

The information is used to accurately identify the applicant so we can review the
applicant’s status, to confirm that the applicant is subject to the 2 year foreign residency
requirement, and to verify that the applicant’s spouse and or child is a LPR/USC as the
waiver’s qualifying extreme hardship is to the applicant’s LPR/USC spouse or child.
The Office of Privacy recommends this is a privacy sensitive form with coverage under
existing PIA and SORN.
PIA


DHS/USCIS/PIA-016(a) Computer Linked Application Information Management
System (CLAIMS 3) and Associated Systems, March 16, 2016 since this is where
information is stored.

SORN


DHS/USCIS-007 Benefits Information System, October 19, 2016, 81 FR 72069, since
the purpose of this system is to permit USCIS' collection, use, maintenance,
dissemination, and storage of paper and electronic benefit request information,
including case processing and decisional data not included in the A-File SORN
(DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking System of
Records, November 21, 2013, 78 FR 69864). These records assist in the processing
of immigrant and nonimmigrant benefit requests from the time when USCIS collects
the information from the benefit requestor until the case reaches a final decision in
the relevant case management system

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

Max Binstock

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1140092
March 14, 2017
March 14, 2020

DESIGNATION
Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

Determination:

☐ PTA sufficient at this time.
☐ Privacy compliance documentation determination in
progress.
☐ New information sharing arrangement is required.
☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.

DHS IC/Forms Review:

DHS PRIV has approved this ICR/Form.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
New e(3) statement is required.
Statement:
Click here to enter text.
PTA:
New system PTA required.
Click here to enter text.
PIA:
System covered by existing PIA
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

If covered by existing PIA, please list: DHS/USCIS/PIA-016(a) Computer
Linked Application Information Management System (CLAIMS 3) and
Associated Systems
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCIS-007 Benefits
Information System, October 19, 2016, 81 FR 72069;
DHS/USCIS/ICE/CBP-001 Alien File, Index, and National File Tracking
System of Records, November 21, 2013, 78 FR 69864
If a SORN update is required, please list: Click here to enter text.
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.
USCIS Privacy is submitting this PTA because Form I-612 provides eligible J-1 and J-2
visa holders the opportunity to apply for a waiver of the requirement to reside and
be physically present in the country of their citizenship or nationality or last foreign
residence for at least two years following departure from the United States.
PRIV finds that is a privacy sensitive system and a PIA is required because Form I612 collects PII from members of the public. PRIV agrees with USCIS Privacy that the
CLAIMS 3 PIA provides coverage. DHS/USCIS/PIA-016(a) discusses the processing of
this form in CLAIMS 3.
PRIV finds that a SORN is required because Form I-612 retrieves information by a
unique identifier. PRIV agrees with USCIS Privacy that the BIS SORN and A-File SORN
provide coverage. DHS/USCIS-007 covers USCIS' collection, use, maintenance,
dissemination, and storage of benefit request information, including case processing
and decisional data not included in the A-file. DHS/USCIS/ICE/CBP-001 covers the
paper and electronic copy A-File and/or Receipt File, supplemental forms,
supplemental evidence, and identity history summaries (formally known as RAP
sheets), but does not include all case processing and decisional data.
PRIV also finds that a PAS is required because Form I-612 asks persons to provide
personal information about themselves, which will go into a system of records.

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