Form I-612 - Application For Waiver Of The Foreign Residence Requirement (Under Section 212(E) Of The Immigration And Nationality Act, As Amended) Page 4

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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 04/24/17 N
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