Fillable Printable Form I-612
Fillable Printable Form I-612
Form I-612
START HERE - Type or print in black ink.►
Part 1. Information About You
4.a.
Family Name
(Last Name)
6.c. Middle Name
6.b. Given Name
(First Name)
6.a. Family Name
(Last Name)
5.a.
4.b.
Given Name
(First Name)
5.b.
4.c.
Middle Name5.c.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
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.
Your Mailing Address
Street Number
and Name
8.b.
8.d.
City or Town
State 8.e. ZIP Code
8.c.
Apt. Flr.Ste.
8.a.
Street Number
and Name
7.b.
7.d.
City or Town
7.f.
State 7.e. ZIP Code
7.g. Postal Code
7.h.
Province
7.c.
Apt. Flr.Ste.
7.a.
Country
9. Marital Status
City/Town/Village of Birth
10. Date of Birth (mm/dd/yyyy)
11.
If you are currently living abroad, enter your last address in the
United States.
Other Information
Your Full Name
Other Names Used (if any)
Alien Registration Number (A-Number) (if any)1.
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A-
For USCIS Use Only
Fee Stamp
Action Block
Remarks
Received Transferred In
Completed Returned/
Transferred Out
USCIS Online Account Number (if any)
3. Social Security Number (if any)
2.
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Widowed
Other
Marriage AnnulledSeparated
DivorcedMarriedSingle, Never Married
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 04/30/2019
Form I-612 04/24/17 N Page 1 of 7
Country of Last Foreign Residence 14.
I believe I am subject to the foreign residence requirement
because (Select all applicable boxes):
2.a.
2.b.
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.
1.
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.
3.
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.
4.
I am applying for a waiver of the foreign residence requirement
because (Select only one box):
My departure from the United States would impose
exceptional hardship on my U.S. citizen or lawful
permanent resident spouse or children.
1.
Part 2. Reason for Foreign Residence
Requirement
Part 3. Reason for Application for Waiver of
Foreign Residence Requirement
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.)
Part 1. Information About You (continued)
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.
Provide 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.
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
3.a.
3.b.
3.c.
Date of Birth (mm/dd/yyyy)
4.
Information About Spouse
5. Country of Birth
Country of Citizenship or Nationality
6.
Country of Last Foreign Residence
7.
12.
Country of Birth
Country of Citizenship or Nationality13.
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.
2.
Form I-612 04/24/17 N Page 2 of 7
Part 3. Reason for Application for Waiver of
Foreign Residence Requirement (continued)
Information About Children
8.a.
Middle Name
18.a. Family Name
(Last Name)
18.b.
Given Name
(First Name)
18.c. Middle Name
13.c.
Given Name
(First Name)
13.b.
Family Name
(Last Name)
13.a.
Family Name
(Last Name)
8.b.
Given Name
(First Name)
8.c. Middle Name
If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
Date of Birth (mm/dd/yyyy)9.
10. Country of Birth
Country of Citizenship or Nationality
11.
Country of Last Foreign Residence
12.
14. Date of Birth (mm/dd/yyyy)
15. Country of Birth
Country of Citizenship or Nationality
16.
Country of Last Foreign Residence
17.
1. Provide all exchange program numbers and names or all
exchange program sponsors.
Part 4. Additional Information About You
Major field of activity (Select only one box):
Business Administration
2.a.
Education
Medicine
Engineering
Humanities
Agriculture
2.b.
2.c.
2.d.
2.e.
2.f.
Other
Natural and Physical Sciences
Social Sciences
2.g.
2.h.
2.i.
Date of last entry into the United States as a J-1 participant
in a designated exchange program (mm/dd/yyyy)
4.
Port-of-Entry (POE) of last arrival in the United States as
a participant in a designated exchange program
5.
If you are now abroad, provide the date of your most
recent departure from the United States (mm/dd/yyyy)
6.
Occupation
3.
If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
City or Town
State
19. Date of Birth (mm/dd/yyyy)
20. Country of Birth
Country of Citizenship or Nationality
21.
Country of Last Foreign Residence
22.
Form I-612 04/24/17 N Page 3 of 7
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)
22.
A-Number (if any)19.
Date of adjustment to lawful permanent resident status
(mm/dd/yyyy)
20.
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A-
Other Information About Lawful Permanent
Resident Spouse or Child
Location where your spouse or children became lawful
permanent residents
21.
City or Town
State
Part 4. Additional Information About You
(continued)
My spouse is filing a separate application for a
waiver of the foreign residence requirement.
My spouse is included in this application.
If you are married, select only one box:
7.a.
7.b.
My spouse is not included in this application.
7.c.
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)
8.c. Middle Name
Naturalization
U.S. citizenship of spouse or child was acquired through
(Select only one box):
Parents
Birth in the United States
9.c.
9.b.
9.a.
Number of Naturalization Certificate
If your spouse or child acquired U.S. citizenship through
naturalization, provide the following information for each
naturalized individual.
10.
Place of Naturalization 12.
City or Town
State
Date of Naturalization (mm/dd/yyyy)11.
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 answered “Yes” to Item Number 13., provide the
information for Item Numbers 14. - 17.
14.
15.
16.
17.
Spouse Certificate of Citizenship Number
Date of Issuance (mm/dd/yyyy)
Child Certificate of Citizenship Number
Date of Issuance (mm/dd/yyyy)
Middle Name18.c.
Given Name
(First Name)
18.b.
Family Name
(Last Name)
18.a.
Name of the lawful permanent resident spouse or child
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.
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.
No
Yes
13. Has your spouse or child obtained a Certificate of
Citizenship?
Form I-612 04/24/17 N Page 4 of 7
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.
,
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.
1.a.
NOTE: Select the box for either Item Number 1.a. or 1.b. If
applicable, select the box for Item Number 2.
2. At my request, the preparer named in Part 7.,
prepared this application for me based only upon
information I provided or authorized.
,
Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
Signature
NOTE: Read the Penalties section of the Form I-612
Instructions before completing this part.
Applicant's Statement
3. Applicant's Daytime Telephone Number
Applicant's Contact Information
Applicant's Email Address (if any)5.
Applicant's Mobile Telephone Number (if any)4.
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.
Applicant's Declaration and Certification
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.
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.
(mm/dd/yyyy)Date of Signature6.b.
Applicant's Signature6.a.
Applicant's Signature
Part 6. Interpreter's Contact Information,
Certification, and Signature
Interpreter's Family Name (Last Name)1.a.
Interpreter's Given Name (First Name)1.b.
2. Interpreter's Business or Organization Name (if any)
Interpreter's Full Name
Provide the following information about the interpreter.
Interpreter's Mailing Address
3.h.
3.c. City or Town
3.d. State 3.e. ZIP Code
3.f. Province
Street Number
and Name
3.a.
Country
3.b. Apt.
Flr.Ste.
3.g. Postal Code
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.
Interpreter's Contact Information
4. Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)6.
Interpreter's Mobile Telephone Number (if any)5.
Form I-612 04/24/17 N Page 5 of 7
(mm/dd/yyyy)Date of Signature6.b.
Interpreter's Signature6.a.
Interpreter's Signature
Part 6. Interpreter's Contact Information,
Certification, and Signature (continued)
Interpreter's Certification
I certify, under penalty of perjury, that:
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.
I am fluent in English and
,
2. Preparer's Business or Organization Name (if any)
1.a. Preparer's Family Name (Last Name)
1.b. Preparer's Given Name (First Name)
Part 7. Contact Information, Declaration, and
Signature of the Person Preparing this
Application, if Other Than the Applicant
Preparer's Full Name
Provide the following information about the preparer.
Preparer's Contact Information
4. Preparer's Daytime Telephone Number
6. Preparer's Email Address (if any)
5. Preparer's Mobile Telephone Number (if any)
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.a.
7.b.
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 Statement
3.d. State 3.e. ZIP Code
3.f. Province
3.h. Country
Preparer's Mailing Address
3.c. City or Town
Street Number
and Name
3.a.
3.b.
Apt.
Flr.Ste.
3.g. Postal Code
8.a. Preparer's Signature
8.b. Date of Signature(mm/dd/yyyy)
Preparer's Signature
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.
Preparer's Certification
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.
Form I-612 04/24/17 N Page 6 of 7
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.
3.d.
1.a Family Name
(Last Name)
1.b. Given Name
(First Name)
1.c.
Middle Name
3.a. 3.b. 3.c.Page Number Part Number Item Number
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A-
A-Number (if any)2.
4.d.
4.a. 4.b. 4.c.Page Number Part Number Item Number
5.d.
5.a. 5.b. 5.c.Page Number Part Number Item Number
Item NumberPart NumberPage Number 7.c.7.b.7.a.
7.d.
6.d.
6.a. 6.b. 6.c.Page Number Part Number Item Number
Form I-612 04/24/17 N Page 7 of 7
