USCIS Form I-612 "Application for Waiver of the Foreign Residence Requirement (Under Section 212(E) of the Immigration and Nationality Act, as Amended)"

What Is USCIS Form I-612?

This is a legal form that was released by the U.S. Department of Homeland Security - Citizenship and Immigration Services on September 17, 2019 and used country-wide. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on September 17, 2019;
  • The latest available edition released by the U.S. Department of Homeland Security - Citizenship and Immigration Services;
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  • Fill out the form in our online filing application.

Download a fillable version of USCIS Form I-612 by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Citizenship and Immigration Services.

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Application for Waiver of the Foreign Residence Requirement
USCIS
(Under Section 212(e) of the INA, as Amended)
Form I-612
Department of Homeland Security
OMB No. 1615-0030
U.S. Citizenship and Immigration Services
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
Your Mailing Address
(USPS ZIP Code Lookup)
1.
Alien Registration Number (A-Number) (if any)
Street Number
7.a.
and Name
A-
7.b.
Apt.
Ste.
Flr.
2.
USCIS Online Account Number (if any)
7.c.
City or Town
3.
Social Security Number (if any)
7.d.
State
7.e. ZIP Code
7.f.
Province
Your Full Name
7.g. Postal Code
4.a.
Family Name
7.h.
Country
(Last Name)
4.b.
Given Name
(First Name)
If you are currently living abroad, enter your last address in the
4.c.
Middle Name
United States.
Street Number
8.a.
Other Names Used (if any)
and Name
8.b.
Apt.
Ste.
Flr.
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
8.c.
City or Town
complete this section, use the space provided in Part 8.
Additional Information.
8.d.
State
8.e. ZIP Code
5.a.
Family Name
(Last Name)
Other Information
5.b.
Given Name
(First Name)
9.
Marital Status
5.c.
Middle Name
Single, Never Married
Married
Divorced
6.a. Family Name
Widowed
Separated
Marriage Annulled
(Last Name)
Other
6.b. Given Name
(First Name)
10.
Date of Birth (mm/dd/yyyy)
6.c. Middle Name
11.
City/Town/Village of Birth
Form I-612 09/17/19
Page 1 of 7
Application for Waiver of the Foreign Residence Requirement
USCIS
(Under Section 212(e) of the INA, as Amended)
Form I-612
Department of Homeland Security
OMB No. 1615-0030
U.S. Citizenship and Immigration Services
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
Your Mailing Address
(USPS ZIP Code Lookup)
1.
Alien Registration Number (A-Number) (if any)
Street Number
7.a.
and Name
A-
7.b.
Apt.
Ste.
Flr.
2.
USCIS Online Account Number (if any)
7.c.
City or Town
3.
Social Security Number (if any)
7.d.
State
7.e. ZIP Code
7.f.
Province
Your Full Name
7.g. Postal Code
4.a.
Family Name
7.h.
Country
(Last Name)
4.b.
Given Name
(First Name)
If you are currently living abroad, enter your last address in the
4.c.
Middle Name
United States.
Street Number
8.a.
Other Names Used (if any)
and Name
8.b.
Apt.
Ste.
Flr.
Provide all other names you have ever used, including aliases,
maiden name, and nicknames. If you need extra space to
8.c.
City or Town
complete this section, use the space provided in Part 8.
Additional Information.
8.d.
State
8.e. ZIP Code
5.a.
Family Name
(Last Name)
Other Information
5.b.
Given Name
(First Name)
9.
Marital Status
5.c.
Middle Name
Single, Never Married
Married
Divorced
6.a. Family Name
Widowed
Separated
Marriage Annulled
(Last Name)
Other
6.b. Given Name
(First Name)
10.
Date of Birth (mm/dd/yyyy)
6.c. Middle Name
11.
City/Town/Village of Birth
Form I-612 09/17/19
Page 1 of 7
2.
Part 1. Information About You (continued)
I cannot return to my country of citizenship or
nationality or last foreign residence because I would
12.
Country of Birth
be subjected to persecution on account of race,
religion, or political opinion.
13.
Country of Citizenship or Nationality
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
14.
Country of Last Foreign Residence
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,
Part 2. Reason for Foreign Residence
your application is incomplete. In your statement, you must
Requirement
also include all pertinent financial information regarding your
and your spouse's income and savings. You must attach any
I believe I am subject to the foreign residence requirement
available evidence that supports your claims of hardship.
because (Select all applicable boxes):
If you selected Part 3., Item Number 2.,you must attach a
1.
I participated in an exchange program that was
statement that details the reasons why you believe you cannot
financed by an agency of the U.S. Government or the
return to your country of citizenship or nationality or last
government of my country of citizenship or nationality
foreign residence because you would be subject to persecution
or last foreign residence, for the purpose of promoting
on account of race, religion, or political opinion. You must also
international education and cultural exchange.
sign and date the statement and attach any available evidence
2.a.
An agency of the U.S. Government or the government
that supports your claims of persecution. (See the What
of my country of citizenship or nationality or last
Evidence Must You Submit section of the Instructions for
foreign residence gave me a grant (such as a Fulbright
additional information.)
grant), stipend, or allowance for the purpose of
List all J-2 dependents that are included in this application. If
participating in an exchange program.
you need extra space to complete this section, use the space
2.b.
Provide the name of the U.S. Government agency or
provided in Part 8. Additional Information.
country of citizenship or nationality or last foreign
residence.
Information About Spouse
3.a.
Family Name
(Last Name)
3.
I became an exchange visitor after the U.S. Secretary
3.b.
Given Name
of State designated my country of citizenship or
(First Name)
nationality or last foreign residence as clearly requiring
the services of persons with my specialized knowledge
3.c.
Middle Name
or skill.
4.
Date of Birth (mm/dd/yyyy)
4.
I entered the United States as, or my status was
changed to, an exchange visitor on or after
5.
Country of Birth
January 10, 1977, to participate in graduate medical
education or training.
6.
Country of Citizenship or Nationality
Part 3. Reason for Application for Waiver of
Foreign Residence Requirement
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
22.
Country of Last Foreign Residence
Part 3. Reason for Application for Waiver of
Foreign Residence Requirement (continued)
Information About Children
Part 4. Additional Information About You
If you need extra space to complete this section, use the space
If you need extra space to complete this section, use the space
provided in Part 8. Additional Information.
provided in Part 8. Additional Information.
8.a.
Family Name
1.
Provide all exchange program numbers and names or all
(Last Name)
exchange program sponsors.
8.b. Given Name
(First Name)
8.c. Middle Name
9.
Date of Birth (mm/dd/yyyy)
10.
Country of Birth
Major field of activity (Select only one box):
2.a.
Agriculture
Country of Citizenship or Nationality
11.
2.b.
Business Administration
2.c.
Education
12.
Country of Last Foreign Residence
2.d.
Engineering
2.e.
Humanities
2.f.
Medicine
13.a.
Family Name
(Last Name)
2.g.
Natural and Physical Sciences
13.b.
Given Name
2.h.
Social Sciences
(First Name)
13.c.
Middle Name
2.i.
Other
3.
Occupation
14.
Date of Birth (mm/dd/yyyy)
15.
Country of Birth
4.
Date of last entry into the United States as a J-1 participant
in a designated exchange program (mm/dd/yyyy)
16.
Country of Citizenship or Nationality
5.
Port-of-Entry (POE) of last arrival in the United States as
a participant in a designated exchange program
17.
Country of Last Foreign Residence
City or Town
18.a. Family Name
State
(Last Name)
6.
If you are now abroad, provide the date of your most
18.b. Given Name
recent departure from the United States (mm/dd/yyyy)
(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
Page 3 of 7
If you answered “Yes” to Item Number 13., provide the
Part 4. Additional Information About You
information for Item Numbers 14. - 17.
(continued)
14.
Spouse Certificate of Citizenship Number
If you are married, select only one box:
7.a.
My spouse is included in this application.
15.
Date of Issuance (mm/dd/yyyy)
7.b.
My spouse is filing a separate application for a
16.
Child Certificate of Citizenship Number
waiver of the foreign residence requirement.
7.c.
My spouse is not included in this application.
17.
Date of Issuance (mm/dd/yyyy)
If you selected Part 3., Item Number 1., provide the following
information about your U.S. citizen spouse or children who you
If you answered “No” to Item Number 13., submit evidence in
believe would suffer exceptional hardship if you resided outside
accordance with the What Evidence Must You Submit section
of the United States for two years following the completion of
of the Instructions.
your U.S. training and departure from the United States.
If you selected Part 3., Item Number 1., provide the following
information about your U.S. citizen spouse or children who you
Name of the U.S. citizen spouse or child
believe would suffer exceptional hardship if you resided outside
8.a. Family Name
of the United States for two years following the completion of
(Last Name)
your U.S. training and departure from the United States.
8.b. Given Name
(First Name)
Name of the lawful permanent resident spouse or child
8.c. Middle Name
18.a.
Family Name
(Last Name)
18.b.
U.S. citizenship of spouse or child was acquired through
Given Name
(Select only one box):
(First Name)
18.c.
Middle Name
9.a.
Birth in the United States
9.b.
Naturalization
Other Information About Lawful Permanent
9.c.
Parents
Resident Spouse or Child
If your spouse or child acquired U.S. citizenship through
19.
A-Number (if any)
naturalization, provide the following information for each
A-
naturalized individual.
20.
Date of adjustment to lawful permanent resident status
Number of Naturalization Certificate
10.
(mm/dd/yyyy)
21.
Location where your spouse or children became lawful
11.
Date of Naturalization (mm/dd/yyyy)
permanent residents
City or Town
12.
Place of Naturalization
State
City or Town
22.
Basis (preference category) for adjusting to lawful
State
permanent resident status (for example, F-2A, Spouse or
unmarried child of an LPR; F-2B, Unmarried sons or
daughters of an LPR)
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
No
Form I-612 09/17/19
Page 4 of 7
Applicant's Signature
Part 5. Applicant's Statement, Contact
Information, Declaration, Certification, and
6.a.
Applicant's Signature
Signature
NOTE: Read the Penalties section of the Form I-612
6.b.
Date of Signature
(mm/dd/yyyy)
Instructions before completing this part.
NOTE TO ALL APPLICANTS: If you do not completely fill
Applicant's Statement
out this application or fail to submit required documents listed
NOTE: Select the box for either Item Number 1.a. or 1.b. If
in the Instructions, USCIS may deny your application.
applicable, select the box for Item Number 2.
1.a.
I can read and understand English, and I have read
Part 6. Interpreter's Contact Information,
and understand every question and instruction on this
Certification, and Signature
application and my answer to every question.
1.b.
The interpreter named in Part 6. read to me every
Provide the following information about the interpreter.
question and instruction on this application and my
Interpreter's Full Name
answer to every question in
1.a.
Interpreter's Family Name (Last Name)
,
a language in which I am fluent, and I understood
everything.
1.b.
Interpreter's Given Name (First Name)
2.
At my request, the preparer named in Part 7.,
,
prepared this application for me based only upon
2.
Interpreter's Business or Organization Name (if any)
information I provided or authorized.
Applicant's Contact Information
Interpreter's Mailing Address
3.
Applicant's Daytime Telephone Number
3.a.
Street Number
and Name
3.b.
Apt.
Ste.
Flr.
4.
Applicant's Mobile Telephone Number (if any)
3.c. City or Town
5.
Applicant's Email Address (if any)
3.d. State
3.e. ZIP Code
3.f.
Province
Applicant's Declaration and Certification
3.g. Postal Code
Copies of any documents I have submitted are exact
photocopies of unaltered, original documents, and I understand
3.h.
Country
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
Interpreter's Contact Information
from any and all of my records that USCIS may need to
determine my eligibility for the immigration benefit that I seek.
4.
Interpreter's Daytime Telephone Number
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
5.
Interpreter's Mobile Telephone Number (if any)
administration and enforcement of U.S. immigration law.
I certify, under penalty of perjury, that all of the information in my
6.
Interpreter's Email Address (if any)
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
Page 5 of 7