Form I-612 - Application For Waiver Of The Foreign Residence Requirement

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OMB No. 1615-0030; Expires 07/31/2012

Form I-612, Application for Waiver of the

Foreign Residence Requirement

Department of Homeland Security

[Under Section 212(e) of the INA, as Amended]

U.S. Citizenship and Immigration Services

Action Block

Fee Stamp

1. Name (Last in CAPS)

First

Middle

1a. If you are a married woman, give your maiden name.

1b. Include all other previously used names, including aliases, tribal names, etc.

2. Mailing Address

(Apt. No.)

(Number and Street)

(Town or City)

(State or Province)

(Country)

(Zip Code, if in U.S.)

Present or last U.S. residence

(Number and Street)

(City)

(Zip Code)

(State)

3. Date of Birth

Place of Birth (City/Town, Province/State/Country)

Country of Citizenship/Nationality

Country of Last Foreign Residence

(mm/dd/yyyy)

(City/Town, Province/State/Country)

Alien Registration Number (A#), (if known)

Telephone Number (With area code)

E-Mail Address, if any

4. I believe I am subject to the foreign residence requirement because: (Check appropriate box(es))

I participated in an exchange program that was financed by an agency of the U.S. Government or the government of the country of my

nationality or last foreign residence for the purpose of promoting international educational and cultural exchange.

An agency of the Government of the United States or the government of the country of my nationality or last foreign residence gave me a grant

(such as a Fullbright grant), stipend or allowance for the purpose of participation in an exchange program. Name of U.S. Government agency

or foreign country:

I became an exchange visitor after the U.S. Secretary of State designated the country of my nationality or last foreign residence as clearly requiring

the services of persons with my specialized knowledge or skill.

I entered the United States as, or my status was changed to, an exchange visitor on or after January 10, 1977, to participate in graduate

medical education or training.

5. I am applying for a waiver of the foreign residence requirement on the ground that: (Check appropriate box(es))

My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse

or child.

I cannot return to the country of my nationality or last foreign residence because I would be subject to persecution on account of race,

religion, or political opinion.

IMPORTANT ADVISORY: If you have checked "A" under Number 5, you must attach to this application a statement dated and signed by you giving a

detailed explanation of the basis for your belief that compliance by you with the 2-year foreign residence requirement of Section 212(e) of the Immigration and

Nationality Act would impose exceptional hardship on your spouse or child who is a citizen of the United States or a lawful permanent resident thereof. Without

such statement your application is incomplete. You must include in the statement all pertinent information concerning the income and savings of yourself and

your spouse. Attach also documentary evidence as may be available to support the allegations of hardship.

If you have checked "B" under Number 5, you must attach a statement dated and signed by you setting forth in detail the reason(s) you believe why you cannot

return to the country of your nationality or last foreign residence because you would be subject to persecution on account of race, religion, or political opinion.

Attach also documentary evidence as may be available to support the allegations of persecution.

6. If married, check appropriate box(es):

(See Page 2 of the Instructions)

My spouse is included in this application.

My spouse is filing a separate application for a waiver.

Remarks

RET'D

RECEIVED

TRANS. IN

COMPLETED

TRANS. OUT

Form I-612 (Rev. 11/23/10) Y