Application for Waiver of the Foreign Residence Requirement (under Section 212(e) of the Immigration and Nationality Act, as Amended)

• Legal Form Number: I-612
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form I-612 Edition 09/07/21

START HERE - Type or print in black ink.►

Part 1. Information About You

4.a.

Family Name

(Last Name)

6.c. Middle Name

6.b. Given Name

(First Name)

6.a. Family Name

(Last Name)

5.a.

4.b.

Given Name

(First Name)

5.b.

4.c.

Middle Name5.c.

Family Name

(Last Name)

Given Name

(First Name)

Middle Name

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.

Your Mailing Address

Street Number

and Name

8.b.

8.d.

City or Town

State 8.e. ZIP Code

8.c.

Apt. Flr.Ste.

8.a.

Street Number

and Name

7.b.

7.d.

City or Town

7.f.

State 7.e. ZIP Code

7.g. Postal Code

7.h.

Province

7.c.

Apt. Flr.Ste.

7.a.

Country

9. Marital Status

City/Town/Village of Birth

10. Date of Birth (mm/dd/yyyy)

11.

If you are currently living abroad, enter your last address in the

United States.

Other Information

Your Full Name

Other Names Used (if any)

Alien Registration Number (A-Number) (if any)1.

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A-

For USCIS Use Only

Fee Stamp

Action Block

Remarks

Received Transferred In

Completed Returned/

Transferred Out

USCIS Online Account Number (if any)

3. Social Security Number (if any)

2.

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Widowed

Other

Marriage AnnulledSeparated

DivorcedMarriedSingle, Never Married

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

USCIS

Form I-612

OMB No. 1615-0030

Expires 09/30/2024

Page 1 of 7

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