Application for Waiver of the Foreign Residence Requirement (Under Section 212(e) of the INA, as Amended) Department of Homeland Security U.S. Citizenship and Immigration Services For USCIS Use Only Action Block Fee Stamp Received USCIS Form I-612 OMB No. 1615-0030 Expires 04/30/2019 Transferred In Completed Returned/ Transferred Out Remarks START HERE - Type or print in black ink. Part 1. Information About You 1. Alien Registration Number (A-Number) (if any) Your Mailing Address 7.a. Street Number and Name 7.b. Apt. Ste. Flr. A2. USCIS Online Account Number (if any) 7.c. City or Town 3. Social Security Number (if any) 7.d. State 7.f. Province 7.e. ZIP Code Your Full Name 4.a. Family Name (Last Name) 4.b. Given Name (First Name) 4.c. Middle Name 7.g. Postal Code 7.h. Country Other Names Used (if any) Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 5.a. Family Name (Last Name) 5.b. Given Name (First Name) 5.c. Middle Name If you are currently living abroad, enter your last address in the United States. 8.a. Street Number and Name 8.b. Apt. Ste. Flr. 8.c. City or Town 8.d. State 8.e. ZIP Code Other Information 9. Marital Status Single, Never Married Married Divorced 6.a. Family Name (Last Name) 6.b. Given Name (First Name) 6.c. Middle Name Widowed Other 10. 11. Separated Marriage Annulled Date of Birth (mm/dd/yyyy) City/Town/Village of Birth Form I-612 04/24/17 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 Part 1. Information About You (continued) 12. Country of Birth 2. I cannot return to my country of citizenship or nationality or last foreign residence because I would be subjected to persecution on account of race, religion, or political opinion. 13. Country of Citizenship or Nationality 14. Country of Last Foreign Residence Part 2. Reason for Foreign Residence Requirement I believe I am subject to the foreign residence requirement because (Select all applicable boxes): 1. I participated in an exchange program that was financed by an agency of the U.S. Government or the government of my country of citizenship or nationality or last foreign residence, for the purpose of promoting international education and cultural exchange. An agency of the U.S. Government or the government of my country of citizenship or nationality or last foreign residence gave me a grant (such as a Fulbright grant), stipend, or allowance for the purpose of participating in an exchange program. Provide the name of the U.S. Government agency or country of citizenship or nationality or last foreign residence. IMPORTANT ADVISORY: If you selected Part 3., Item Number 1., you must attach a statement providing a detailed explanation why you believe that your compliance with the two-year foreign residence requirement of INA section 212(e) would impose exceptional hardship on your U.S. citizen or lawful permanent resident spouse or children. You must sign and date the statement. If you do not include this statement, your application is incomplete. In your statement, you must also include all pertinent financial information regarding your and your spouse's income and savings. You must attach any available evidence that supports your claims of hardship. If you selected Part 3., Item Number 2.,you must attach a statement that details the reasons why you believe you cannot return to your country of citizenship or nationality or last foreign residence because you would be subject to persecution on account of race, religion, or political opinion. You must also sign and date the statement and attach any available evidence that supports your claims of persecution. (See the What Evidence Must You Submit section of the Instructions for additional information.) List all J-2 dependents that are included in this application. If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 2.a. 2.b. Information About Spouse 3.a. Family Name (Last Name) 3.b. Given Name (First Name) 3.c. Middle Name 4. 5. Date of Birth (mm/dd/yyyy) Country of Birth 3. I became an exchange visitor after the U.S. Secretary of State designated my country of citizenship or 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. 4. 6. Country of Citizenship or Nationality Part 3. Reason for Application for Waiver of Foreign Residence Requirement I am applying for a waiver of the foreign residence requirement because (Select only one box): 1. My departure from the United States would impose exceptional hardship on my U.S. citizen or lawful permanent resident spouse or children. 7. Country of Last Foreign Residence Form I-612 04/24/17 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Part 3. Reason for Application for Waiver of Foreign Residence Requirement (continued) Information About Children If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 8.a. Family Name (Last Name) 8.b. Given Name (First Name) 8.c. Middle Name 9. 10. Date of Birth (mm/dd/yyyy) Country of Birth 22. Country of Last Foreign Residence Part 4. Additional Information About You If you need extra space to complete this section, use the space provided in Part 8. Additional Information. 1. Provide all exchange program numbers and names or all exchange program sponsors. Major field of activity (Select only one box): 2.a. Agriculture Business Administration Education Engineering Humanities Medicine Natural and Physical Sciences Social Sciences Other Occupation 11. Country of Citizenship or Nationality 2.b. 2.c. 12. Country of Last Foreign Residence 2.d. 2.e. 13.a. Family Name (Last Name) 13.b. Given Name (First Name) 13.c. Middle Name 14. 15. Date of Birth (mm/dd/yyyy) Country of Birth 2.f. 2.g. 2.h. 2.i. 3. 4. 16. Country of Citizenship or Nationality 5. 17. Country of Last Foreign Residence Date of last entry into the United States as a J-1 participant in a designated exchange program (mm/dd/yyyy) Port-of-Entry (POE) of last arrival in the United States as a participant in a designated exchange program City or Town 18.a. Family Name (Last Name) 18.b. Given Name (First Name) 18.c. Midd