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 09/30/2021

For USCIS Use Only
Action Block

Fee Stamp

Received

Transferred In

Completed

Returned/
Transferred Out

Remarks

► START HERE - Type or print in black ink.

Part 1. Information About You
1.

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

2.

3.

USCIS Online Account Number (if any)
►
Social Security Number (if any)
►

Your Mailing Address
7.a. Street Number
and Name
7.b.

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

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. Family Name
(Last Name)
5.b. Given Name
(First Name)

Apt.

Ste.

Flr.

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

Your Full Name

(USPS ZIP Code Lookup)

7.e. ZIP Code

Province

7.g. Postal Code
7.h. Country

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

Apt.

Ste.

Flr.

8.c. City or Town
8.d. State

8.e. ZIP Code

Other Information
9.

Marital Status

5.c. Middle Name
Single, Never Married
6.a. Family Name
(Last Name)
6.b. Given Name
(First Name)

Widowed

Separated

Married

Divorced

Marriage Annulled

Other
10.

Date of Birth (mm/dd/yyyy)

11.

City/Town/Village of Birth

6.c. Middle Name

Form I-612 09/17/19

Page 1 of 7

Part 1. Information About You (continued)
12.

Country of Birth

13.

Country of Citizenship or Nationality

14.

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.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.

3.

4.

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

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.

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

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 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 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 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 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. Given Name
(First Name)
3.c. Middle Name
4.

Date of Birth (mm/dd/yyyy)

5.

Country of Birth

6.

Country of Citizenship or Nationality

7.

Country of Last Foreign Residence

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.

Form I-612 09/17/19

Page 2 of 7

Part 3. Reason for Application for Waiver of
Foreign Residence Requirement (continued)
Information About Children
If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
8.a. Family Name
(Last Name)
8.b. Given Name
(First Name)
8.c. Middle Name
9.

Date of Birth (mm/dd/yyyy)

10.

Country of Birth

11.

12.

Country of Citizenship or Nationality

Country of Last Foreign Residence

13.a. Family Name
(Last Name)
13.b. Given Name
(First Name)
13.c. Middle Name
14.

Date of Birth (mm/dd/yyyy)

15.

Country of Birth

16.

Country of Citizenship or Nationality

17.

Country of Last Foreign Residence

22.

Country of Last Foreign Residence

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.

Provide 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 J-1 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

18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)
18.c. Middle Name
19.

Date of Birth (mm/dd/yyyy)

20.

Country of Birth

21.

Country of Citizenship or Nationality

Form I-612 09/17/19

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

If you answered “Yes” to Item Number 13., provide the
information for Item Numbers 14. - 17.

Part 4. Additional Information About You
(continued)

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

18.a. Family Name
(Last Name)
18.b. Given Name
(First Name)

U.S. citizenship of spouse or child was acquired through
(Select only one box):
Birth in the United States

9.b.

Naturalization

9.c.

Parents

18.c. Middle Name

Other Information About Lawful Permanent
Resident Spouse or Child

If your spouse or child acquired U.S. citizenship through
naturalization, provide the following information for each
naturalized individual.
10.

Number of Naturalization Certificate

11.

Date of Naturalization (mm/dd/yyyy)

12.

Place of Naturalization

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.
Name of the lawful permanent resident spouse or child

8.c. Middle Name

9.a.

If you answered “No” to Item Number 13., submit evidence in
accordance with the What Evidence Must You Submit section
of the Instructions.

19.

► A20.

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

21.

Location where your spouse or children became lawful
permanent residents
City or Town
State

City or Town
22.
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.
13.

Has your spouse or child obtained a Certificate of
Citizenship?
Yes

Form I-612 09/17/19

A-Number (if any)

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 7

Applicant's Signature

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

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

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)

a language in which I am fluent, and I understood
everything.
2.

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

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)

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
5.

Applicant's Email Address (if any)

3.d. State
3.f.

3.e. ZIP Code

Province

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 Service (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.
Form I-612 09/17/19

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)

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.

6.

Preparer's Email Address (if any)

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.

Interpreter's Signature

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.

Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and

,

6.a. Interpreter's Signature

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

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 Statement

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.

Preparer's Full Name

Preparer's Certification

1.a. Preparer's Family Name (Last 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 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.

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.

8.a. Preparer's Signature
Ste.

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

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

Preparer's Signature

3.e. ZIP Code

Province

3.g. Postal Code
3.h. Country

Form I-612 09/17/19

Page 6 of 7

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. 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.

5.b. Part Number

5.c. Item Number

6.b. Part Number

6.c. Item Number

7.b. Part Number

7.c. Item Number

5.d.

1.a

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

A-Number (if any) ► A-

3.a. Page Number

3.b. Part Number

3.c. Item Number

6.d.

3.d.

4.a. Page Number

4.d.

Form I-612 09/17/19

6.a. Page Number

4.b. Part Number

4.c. Item Number

7.a. Page Number

7.d.

Page 7 of 7