Form I-612 - Application For Waiver Of The Foreign Residence Requirement (Under Section 212(E) Of The Immigration And Nationality Act, As Amended)

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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 04/30/2019
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
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 04/24/17 N
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