Form I-612 - Application For Waiver Of The Foreign Residence Requirement (Under Section 212(E) Of The Immigration And Nationality Act, As Amended) Page 2
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72.
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 04/24/17 N
Page 2 of 7
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