Form I-612 - Application For Waiver Of The Foreign Residence Requirement (Under Section 212(E) Of The Immigration And Nationality Act, As Amended) Page 5
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7Applicant'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
6.
Interpreter's Email Address (if any)
my 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 04/24/17 N
Page 5 of 7
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