OMB No. 1615-0030; Expires 07/31/2012 Form I-612, Application for Waiver of the Foreign Residence Requirement Department of Homeland Security U.S. Citizenship and Immigration Services [Under Section 212(e) of the INA, as Amended] Fee Stamp Action Block 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) Present or last U.S. residence 3. Date of Birth (mm/dd/yyyy) (Town or City) (Number and Street) Place of Birth (City/Town, Province/State/Country) (State or Province) (City) (Zip Code, if in U.S.) (Country) (Zip Code) (State) Country of Last Foreign Residence (City/Town, Province/State/Country) Telephone Number (With area code) Alien Registration Number (A#), (if known) Country of Citizenship/Nationality E-Mail Address, if any 4. I believe I am subject to the foreign residence requirement because: (Check appropriate box(es)) A. 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. B. 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: C. 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. D. 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)) A. My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse or child. B. 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): A. (See Page 2 of the Instructions) My spouse is included in this application. B. My spouse is filing a separate application for a waiver. Remarks RECEIVED TRANS. IN RET'D TRANS. OUT COMPLETED Form I-612 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com 7. List all program numbers and names of all program sponsors. 8. Major field of activity (Check one) 9. Occupation (1) Agriculture (4) Engineering (7) Natural and Physical Sciences (2) Business Administration (5) Humanities (8) Social Sciences (3) Education (6) Medicine (9) Other 10. Date and port of last arrival in the United States as a participant in a designated exchange program. 12. Number of prior marriages of applicant 11. If you are now abroad, give date of departure from United States. If married, number of prior marriages of applicant's spouse 13. Name of Spouse Date and Country of Birth Nationality/Citizenship Country of Last Foreign Residence 14. Names of Children Date and Country of Birth Nationality/Citizenship Country of Last Foreign Residence 15. If you checked "A" under Number 5 on Page 1 of this form, provide the following information concerning your spouse or one of your children who is a citizen of the United States and who you believe would suffer exceptional hardship if you resided outside the United States for 2 years following your departure from this country. U.S. citizenship of spouse or child was acquired through (Check one) Name of U.S. citizen spouse or child: Birth in the United States Naturalization Parent(s) If the U.S. citizenship of spouse or child was acquired through naturalization, give the following: Number of Naturalization Certificate Date of Naturalization Place of Naturalization If the U.S. citizenship of spouse or child was acquired through parent(s), has the spouse or child obtained a Certificate of Citizenship? If yes, give the number of the certificate If no, submit evidence in accordance with Page 2 of the Instructions. 16. If you checked "A" under Number 5 on Page 1 of this form and you do not have a spouse or child who is a citizen of the United States, provide the following information concerning your spouse or one of your children who is a lawful permanent resident of the United States and who you believe would suffer exceptional hardship if you resided outside the United States for 2 years following your departure from this country. Name of lawful resident alien spouse or child: Alien Registration Number (A#): Date, place, and means of admission for lawful permanent residence: 17. APPLICANT'S CERTIFICATION: I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct. Executed on (Date) (Place) (Signature of applicant) SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN APPLICANT: I declare that this document was prepared by me at the request of the applicant and is based on all information of which I have any knowledge: (Date) (Signature) ( (Address of person preparing form, if other than applicant) (Occupation) (Telephone Number) (E-Mail Address, if any) ) Form I-612 (Rev. 11/23/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com