Form I-612 - Application For Waiver Of The Foreign Residence Requirement (Under Section 212(E) Of The Immigration And Nationality Act, As Amended) Page 6

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Part 6. Interpreter's Contact Information,
Preparer's Contact Information
Certification, and Signature (continued)
4.
Preparer's Daytime Telephone Number
Interpreter's Certification
5.
Preparer's Mobile Telephone Number (if any)
I certify, under penalty of perjury, that:
I am fluent in English and
,
6.
Preparer's Email Address (if any)
which is the same language specified in Part 5., Item Number
1.b., and I have read to this applicant in the identified language
every question and instruction on this application and his or her
answer to every question. The applicant informed me that he or
Preparer's Statement
she understands every instruction, question, and answer on the
application, including the Applicant's Declaration and
I am not an attorney or accredited representative but
7.a.
Certification, and has verified the accuracy of every answer.
have prepared this application on behalf of the
applicant and with the applicant's consent.
Interpreter's Signature
I am an attorney or accredited representative and my
7.b.
representation of the applicant in this case
6.a.
Interpreter's Signature
extends
does not extend beyond the
preparation of this application.
NOTE: If you are an attorney or accredited
6.b.
Date of Signature
(mm/dd/yyyy)
representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of
Appearance as Attorney or Accredited
Part 7. Contact Information, Declaration, and
Representative, or Form G-28I, Notice of Entry of
Signature of the Person Preparing this
Appearance as Attorney In Matters Outside the
Application, if Other Than the Applicant
Geographical Confines of the United States, with this
application.
Provide the following information about the preparer.
Preparer's Full Name
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I
1.a. Preparer's Family Name (Last Name)
prepared this application at the request of the applicant. The
applicant then reviewed this completed application and informed
me that he or she understands all of the information contained in,
1.b. Preparer's Given Name (First Name)
and submitted with, his or her application, including the
Applicant's Declaration and Certification, and that all of this
information is complete, true, and correct. I completed this
2.
Preparer's Business or Organization Name (if any)
application based only on information that the applicant provided
to me or authorized me to obtain or use.
Preparer's Mailing Address
Preparer's Signature
3.a.
Street Number
8.a. Preparer's Signature
and Name
3.b.
Apt.
Ste.
Flr.
8.b. Date of Signature (mm/dd/yyyy)
3.c. City or Town
3.d. State
3.e. ZIP Code
3.f.
Province
3.g. Postal Code
3.h. Country
Form I-612 04/24/17 N
Page 6 of 7

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