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I-612, Application for Waiver of the Foreign Residence Requirement (United States)

This form is to waive foreign residence requirement in the United States. The form provided here is simply a sample of what the actual Form I-612 looks like.

U.S. Department of Homeland Security
Bureau of Citizenship and Immigration Service

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

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Action Block

Fee Stamp

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1. Name (Last in CAPS) _______________________________

First _______________________________

Middle _______________________________

1a. If you are a married woman, give your maiden name _______________________________

1b. Include all other previously used names, including aliases, tribal names, etc. _______________________________

2. Mailing Address (Apt. No.) _______________________________

(Number and Street) _______________________________

(Town or City) _______________________________

(State or Province) _______________________________

(Country) _______________________________

(Zip Code) _______________________________

3. Date of Birth (mm/dd/yyyy) _______________________________

Place of Birth (City/Town, Province/State/Country) _______________________________

Country of Citizenship/Nationality _______________________________

Country of Last Foreign Residence (City/Town, Province/State/Country) _______________________________

Alien Registration Number (A#), (if known) _______________________________

Telephone Number (With area code) _______________________________

E-Mail Address, if any _______________________________

4. I believe I am subject to the foreign residence requirements because: (Check appropriate box(es)).

A. ____ I participated in an exchange program that was financed by an agency of the U.S. Government or the government of the country of my nationality or last foreign residence for the purpose of promoting international educational and cultural exchange.

B. ____ An agency of the Government of the United States or the government of the country of my nationality or last foreign residence gave me a grant (such as a Fulbright grant), stipend or allowance for the purpose of participation in an exchange program. Name of U.S. Government agency or foreign country: _______________________________

C. ____ I became an exchange visitor after the U.S. Secretary of State designated the country of my nationality or last foreign residence as clearly requiring the services of persons with my specialized knowledge or skill.

D. ____ I entered the United States as, or my status was changed to that of, an exchange visitor on or after January 10, 1977 to participate in graduate medical education or training.

5. I am applying for a waiver of the foreign residence requirement on the ground that: (Check appropriate box(es)).

A. ____ My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse or child.

B. ____ I cannot return to the country of my nationality or last foreign residence because I would be subject to persecution on account of race, religion or political opinion.

IMPORTANT ADVISORY: If you have checked "A" under Number 5, you must attach to this application a statement dated and signed by you giving a detailed explanation of the basis for your belief that compliance by you with the two-year foreign residence requirement of Section 212(e) of the Immigration and Nationality Act, as amended, would impose exceptional hardship on your spouse or child who is a citizen of the United States or a lawful permanent resident thereof. Without such statement your application is incomplete. You must include in the statement all pertinent information concerning the income and savings of yourself and your spouse. Attach also documentary evidence as may be available to support the allegations of hardship.

If you have checked "B" under Number 5, you must attach a statement dated and signed by you setting forth in detail the reason(s) you believe why you cannot return to the country of your nationality or last foreign residence because you would be subject to persecution on account of race, religion or political opinion. Attach also documentary evidence as may be available to support the allegations of persecution.

6. If married, check appropriate box(es): (See Instructions, Number 4, Spouse of Applicant.)

A. ____ My spouse is included in this application.

B. ____ My spouse is filing a separate application for a waiver.

7. List all program numbers and names of all program sponsors.

_______________________________

8. Major field of activity (Check one)

____ (1) Agriculture

____ (2) Business Administration

____ (3) Education

____ (4) Engineering

____ (5) Humanities

____ (6) Medicine

____ (7) Natural and Physical Sciences

____ (8) Social Sciences

____ (9) Other _______________________________

9. Occupation _______________________________

10. Date and port of last arrival in the United States as a participant in a designated exchange program. _______________________________

11. If you are now abroad, give date of departure from United States. _______________________________

12. Number of prior marriages of applicant _______________________________

If married, number of prior marriages of applicant's spouse _______________________________

13. Name of Spouse _______________________________

Date and Country of Birth _______________________________

National/Citizenship _______________________________

Country of Last Foreign Residence _______________________________

14. Name of Children _______________________________

Date and Country of Birth _______________________________

National/Citizenship _______________________________

Country of Last Foreign Residence _______________________________

15. If you checked "A" under Number 5 on Page 1 of this form, provide the following information concerning your spouse or one of your children who is a citizen of the United States and who you believe would suffer exceptional hardship if you resided outside the United States for two years following your departure from this country.

If the U.S. citizenship of spouse or child was acquired through naturalization, give the following:

Name of U.S. citizen spouse or child: _______________________________

U.S. citizenship of spouse or child was acquired through (check one)

____ Birth in the United States ____ Naturalization ____ Parent(s)


Number of Naturalization Certificate _______________________________

Date of Naturalization _______________________________

Place of Naturalization _______________________________

If the U.S. citizenship of spouse or child was acquired through parent(s), has the spouse or child obtained a Certificate of Citizenship? _______________________________

If so, give the number of the certificate ________________________ If not, submit evidence in accordance with Instruction 6(a) (2), Supporting Documents.

16.If you checked "A" under Number 5 on Page 1 of this form and you do not have a spouse or child who is a citizen of the United States, provide the following information concerning your spouse or one of your children who is a lawful permanent resident of the United States and who you believe would suffer exceptional hardship if you resided outside the United States for two years following your departure from this country.

Name of lawful resident alien spouse or child: _______________________________

Alien Registration Number (A#) _______________________________

Date, place and means of admission for lawful permanent residence: _______________________________

17. APPLICANT'S CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. _______________________________

Executed on: _______________________________ (Date)

_______________________________ (Place)

_______________________________ (Signature of applicant)


SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT:
I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge:

_______________________________ (Signature)

_______________________________ (Date)

_______________________________ (Occupation)

_______________________________ (Address of person preparing form, if other than application)

_______________________________(Telephone Number)

_______________________________ (E-Mail Address, if any)


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INSTRUCTIONS FOR FILLING OUT THIS FORM
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NOTE: This application may be submitted only by an alien who believes that compliance with the foreign residence requirement of Section 212(e) of the Immigration and Nationality Act, as amended, would impose exceptional hardship on his or her spouse or child who is a citizen of the United States or a lawful permanent resident thereof, or by an alien who believes that returning to the country of his or her nationality or last residence would subject him or her to persecution on account of race, religion or political opinion.

NOTE: Please read these instructions carefully. The application fee will not be refunded.

1. Foreign Residence Requirement.

In order to be eligible to apply for an immigrant visa or for permanent residence in the United States, or for a nonimmigrant visa as a temporary worker, certain exchange visitors (visa symbols J-1 and J-2) must reside and be physically present in the country of their nationality or last foreign residence for an aggregate of at least two years following departure from the United States.

An exchange visitor is subject to the two-year foreign residence requirements if:

His or her participation in the exchange program was financed at any time in whole or in part, directly or indirectly, by an agency of the U.S. Government or by the government of his or her country of nationality or last foreign residence; or

Prior to issuance of an exchange visitor visa, or admission as an exchange visitor without a visa, or acquisition of status as an exchange visitor, to participate in an exchange program, his or her country of nationality or last foreign residence was designated by the U.S. Secretary of State as clearly requiring the alien's specialized knowledge or skill;


He or she entered the United States as, or changed status to that of an exchange visitor on or after January 10, 1977, to participate in graduate medical education or training.

If a participant in an exchange program is subject to the two-year foreign residence requirement, his or her spouse and unmarried minor children who were admitted as exchange visitors or acquired such status after admission are also subject to this requirement. If you have any question as to whether you are subject to the two-year foreign residence requirement, the nearest U.S. Citizenship and Immigration Services (USCIS) office or American embassy or consulate will respond to your concerns.

2. Eligibility for Waiver of the Two-Year Foreign Residence Requirement.

Waiver of the two-year foreign residence requirement may be authorized only under the following circumstances:

The alien has a U.S citizen or permanent resident spouse or unmarried minor child and establishes in an application to the USCIS that compliance with the two-year foreign residence requirement would impose exceptional hardship on such spouse or child.

The alien established in an application to the USCIS that returning to his or her country of nationality or last foreign residence would subject him or her to persecution on account of race, religion or political opinion.

A U.S. government agency requests the U.S. Secretary of State to recommend a waiver on the alien's behalf for the reason that compliance with the two-year foreign residence requirement would be detrimental to a program or activity of official interest to the agency.

The country of the alien's nationality or last foreign residence furnishes the U.S. Secretary of State a written statement that it has no objection to the waiver.

NOTE: This waiver is not available to the alien who came to the United States on or after January 10, 1977 as an exchange visitor, or who acquired such status on or after that date in order to receive graduate medical education or training.

In no case may the two-year foreign requirement be waived unless a favorable recommendation is made by the Director of the U.S. Information Agency to the Secretary, Department of Homeland Security.

An alien, who believes that a U.S. Government agency may be officially interested in his or her case and may wish to request a waiver on his or her behalf, should inquire directly to that agency concerning such request.

An alien who seeks a waiver of the foreign residence requirement on the basis that the foreign country of his or her citizenship/nationality or last foreign residence has no objection to the waiver should, if in the United States, apply directly to the embassy of the country concerned; or if abroad, should inquire at his to her foreign ministry.

3. Submission of Application.

If you live in Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, the U.S. Virgin Islands, Vermont, Virginia or West Virginia, mail your application to:

USCIS Vermont Service Center
75 Lower Welden Street
St. Albans, VT 05479-0001

If you live in Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee or Texas, mail your application to:

USCIS Texas Service Center
P.O. Box 851182
Mesquite, TX 75185-1182

If you live in Arizona, California, Guam, Hawaii or Nevada, mail your application to:

USCIS California Service Center,
P.O. Box 10539
Laguna Niguel, CA 92607-1053

If you live elsewhere in the United States, mail your application to:

USCIS Nebraska Service Center
P.O. Box 87539
Lincoln, NE 68501-7539

4. Spouse of Applicant.

If your spouse is or was an exchange alien who is subject to the foreign residence requirement solely because of a relationship to you, he or she may be included in this application by checking "A" in Block 6 of the application.

If your spouse is subject to the foreign residence requirement because of participation in an exchange program, your spouse may apply for a waiver of the foreign residence requirement by submitting a separate application on Form I-612. In such case, "B" should be checked in Block 6 on each application.

5. Preparation of Application.

The application must be typed or printed legibly in black ink, using block letters.

6. Supporting Documents.

The following documents must be submitted with this application:

A. To prove U.S. citizenship of a spouse or child, if you check "A" in Block 5.

1. If your spouse or child is a citizen by reason of birth in the United States, submit (a) a birth certificate of the spouse or child; or (b) if a birth certificate is unobtainable, a copy of the baptismal certificate (baptism must have occurred within two months after birth) under seal of the church, showing the place of birth; or (c) if the birth or baptismal certificate cannot be obtained, affidavits of two U. S. citizens who have personal knowledge of the birth of your spouse or child in the United States.

2. If your spouse or child was born outside the United States, became a citizen of the United States through a parent, and has not been issued a certificate of citizenship, submit evidence of the citizenship and marriage of parent, as well as termination of any prior marriages of parent. Also submit a birth certificate of the child and a separate statement showing the dates, ports and means of all arrivals and departures into and from the United States by the spouse or child.

3. If the naturalization of your spouse or child occurred within 90 days immediately preceding the filing of this application, submit a copy of the naturalization certificate.

B. To prove a relationship between the applicant and a spouse or child, if you check "A" in Block 5:

Every application must be accompanied by a certificate of marriage to the spouse and proof of legal termination of all previous marriages of the applicant and spouse. If the application is based on hardship to a child, also submit the birth certificate of the child.

C. To support your application for a waiver: In addition to your own required statement, you may submit any documentary evidence available that you believe affects the exceptional hardship or persecution issues.

D. If you are in the United States, you must submit your temporary entry permit (Form I-94, Arrival-Departure Record) and the entry permit of your spouse, if he or she is in the United States and not a U.S. citizen or lawful permanent resident. If the entry permit is attached to the passport, remove and submit it for this purpose. Do not submit the passport.

7. Documents in General.

You must submit originals of all supporting documents. If you want to have the originals of any of the documents returned, and if copies are by law permitted to be made, you may submit photocopies or typed copies with the originals and the originals will be returned to you. However, a photocopy or other machine-made copy unaccompanied by the original document may be accepted if the copy bears a certification by a USCIS or American Consular officer that the copy was compared with the original and found to be identical. Any document in a foreign language must be accompanied by a translation in English. The translator must certify that he is competent to translate and that the translation is accurate.

8. Penalties.

If you knowingly and willfully falsify or conceal a material fact or submit a false document with this request, we will deny the benefit you are seeking and may deny any other immigration benefit. In addition, you will face severe penalties provided by law and may be subject to criminal prosecution.

9. What Is the Fee?

A fee of $265.00 must be paid for filing this application.

The fee cannot be refunded regardless of the action taken on the application. Do not mail cash. All fees must be submitted in the exact amount.

Payment by check or money order must be drawn from a bank or other institution located in the United States and be payable in United States currency.

If the applicant resides in Guam, the check or money order must be payable to the "Treasurer, Guam."

If the applicant resides in the U.S. Virgin Islands, the check or money order must be payable to the "Commissioner of Finance of the Virgin Islands."

All other applicants must make the check or money order payable to the Department of Homeland Security.

When the check is drawn on account of a person other than the applicant, the name of the applicant must be entered on the face of the check. If the application is submitted from outside the United States, remittance may be made by bank international money order or foreign draft drawn on a financial institution in the United States and payable to the Department of Homeland Security in U.S. currency.

Personal checks are accepted subject to collection. An uncollected check will render the application and any document issued pursuant thereto invalid. A charge of $30.00 will be imposed if a check in payment of a fee is not honored by the bank on which it is drawn.

How to Check If the Fee Is Correct.

The fee on this form is current as of the edition date appearing in the lower right corner of this page. However, because USCIS fees change periodically, you can verify if the fee is correct by following one of the steps below:

• Visit our website at www.uscis.gov and scroll down to "Forms and E-Filing" to check the appropriate fee, or

• Review the Fee Schedule included in your form package, if you called us to request the form, or

• Telephone our National Customer Service Center at 1-800-375-5283 and ask for the fee information.

10. USCIS Forms and Information.

To order USCIS forms, call our toll-free forms line at 1-800-870-3676. You can also obtain information on immigration laws, regulations or procedures by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our internet website at www.uscis.gov.

11. Use InfoPass to Make an Appointment.

As an alternative to waiting in line for assistance at your local USCIS office, you can now schedule an appointment through our internet-based system, InfoPass. To access the system, visit our website at www.uscis.gov. Use the InfoPass appointment scheduler and follow the screen prompts to set up your appointment. InfoPass generates an electronic appointment notice that appears on the screen. Print the notice and take it with you to your appointment. The notice gives the time and date of your appointment, along with the address of the USCIS office.

12. Public Reporting Burden.

A person is not required to respond to a collection of information unless it displays a currently valid OMB control number.

The reporting burden for this collection of information is estimated to average 20 minutes per response, including the time of reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

If you have comments regarding the accuracy of this estimate or suggestions for making this form simpler, you may write to the U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., Washington, DC 20529; OMB No.1615-0026. Do not mail your completed petition to this address.

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