Form Supplement 1, List Supplement 1, List Supplement 1

Supplement 1,
Listing of Adult Member of the Household
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-600A/I-600
Supplement 1
OMB No. 1615-0028
Expires 02/28/2017

Part 1. Information About an Adult Member of the Household
You must complete Form I-600A/Form I-600, Supplement 1, for each adult member of your household 18 years of age or older.
Note you do not need to complete one for yourself or your spouse (if married).
Provide the following information about the Adult Member of the Household:
1.

Family Name (Last Name)

2.

Other Names You Have Used (including maiden name, nicknames, and aliases, if any)
Family Name (Last Name)
Given Name (First Name)

3.

4.

Given Name (First Name)

Middle Name (if applicable)

Middle Name (if applicable)

U.S. Mailing Address (if any)
In Care Of Name

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Yes

Is your current U.S. mailing address the same as your U.S. physical address?

No

If you answered "No" to Item Number 4., provide your U.S. physical address in Item Number 5. or your address abroad in Item
Number 6., as appropriate.
5.

6.

U.S. Physical Address (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Address Abroad (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

7.

Date of Birth (mm/dd/yyyy)

Postal Code

8.

Form I-600A/I-600 Supplement 1 02/01/15 N

ZIP Code

Country

City/Town/Village of Birth

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Part 1. Information About an Adult Member of the Household (continued)
9.

State or Province of Birth

10. Country of Birth

11. Alien Registration Number (A-Number) (if any)
► A-

Duty of Disclosure
You must answer each of the following questions. See the Duty of Disclosure section in the Form I-600A or Form I-600 instructions,
concerning your ongoing duty to disclose information in response to these questions. If you answer "Yes" to any of these questions,
provide a certified copy of the documentation showing the final disposition of each incident which resulted in arrest, indictment,
conviction, and/or any other judicial or administrative action and a written statement giving details, including any mitigating
circumstances about each arrest, signed by the adult member of the household under penalty of perjury under U.S. law. The written
statement must show the date of each incident; place incident occurred (city/town, state/province, country); name of police department
or other law enforcement administration or other entity involved; and date of incarceration and name of facility, if applicable. Provide
a description of any type of counseling, rehabilitation, or other information that you and the adult member of the household would like
considered in light of this history on a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet;
indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
12. Has the adult member of the household EVER, whether in or outside the United States:
A. Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law
or ordinance, excluding traffic violations, but including driving or operating a vehicle while intoxicated
or while impaired by or under the influence of alcohol or other intoxicant, even if the record of the
arrest, conviction, or other adverse criminal history was expunged, sealed, pardoned, or the subject of
any other amelioration?

Yes

No

B. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?

Yes

No

C. Received a suspended sentence, been placed on probation or parole, or in an alternative sentencing or
rehabilitation program, such as diversion, deferred prosecution, deferred or withheld adjudication, or
expungement of a criminal charge?

Yes

No

D. At any time been the subject of any investigation by any child welfare agency, court, or other official
authority in any State or foreign country concerning the abuse or neglect of any child, other than an
investigation that has been completed and formally closed based on a finding that the allegation of abuse
or neglect was unfounded or unsubstantiated?

Yes

No

Part 2. Information About You (Applicant or Petitioner Filing Form I-600A/I-600)
1.

Family Name (Last Name)

Given Name (First Name)

2.

Date of Birth (mm/dd/yyyy)

4.

State or Province of Birth

6.

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

3.

Middle Name (if applicable)

City/Town/Village of Birth

5.

Country of Birth

► A-

Form I-600A/I-600 Supplement 1 02/01/15 N

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Part 3. Adult Member of the Household's Statement, Contact Information, Certification, and Signature
Adult Member of the Household's Statement
Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2.
1.A.

I can read and understand English, and have read and understand every question and instruction on this supplement, as well as
my answer to every question.

1.B.

The interpreter named in Part 6. has read to me every question and instruction on this supplement, as well as my answer
to every question, in
, a language in which I am fluent.
I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided
complete, true, and correct responses.

2.

I have requested the services of and consented to
who

is

,

is not an attorney or accredited representative, preparing this supplement for me.

Adult Member of the Household's Contact Information
3.

Adult Member of the Household's Daytime Telephone Number 4. Adult Member of the Household's Mobile Telephone Number (if any)

5.

Adult Member of the Household's Email Address (if any)

Adult Member of the Household's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine the suitability and eligibility of the applicant or petitioner as an adoptive
parent.
I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records to
other entities and persons where necessary for the administration of U.S. immigration laws.
I certify, under penalty of perjury, that the information in my supplement and any document submitted with my supplement is
complete, true, and correct.

Adult Member of the Household's Signature
6.

Adult Member of the Household's Signature

Date of Signature
(mm/dd/yyyy)

Part 4. Adult Member of the Household's Duty of Disclosure
Certification: I understand the ongoing duty to disclose information concerning any change of circumstance, as described in the
Form I-600A and/or Form I-600 instructions, and I agree to notify the applicant, petitioner, and/or home study preparer and USCIS of
any new information that I am required to disclose.
Adult Member of the Household's Signature

Date of Signature
(mm/dd/yyyy)

Form I-600A/I-600 Supplement 1 02/01/15 N

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Part 5. Applicant's or Petitioner's Statement, Contact Information, Certification, and Signature
Applicant's or Petitioner's Statement
Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2.
1.A.

I can read and understand English, and have read and understand every question and instruction on this supplement, as well as
my answer to every question.

1.B.

The interpreter named in Part 6. has read to me every question and instruction on this supplement, as well as my answer
to every question, in
, a language in which I am fluent.
I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided
complete, true, and correct responses.

2.

I have requested the services of and consented to
who

is

,

is not an attorney or accredited representative, preparing this supplement for me.

Applicant's or Petitioner's Contact Information
3.

Applicant's or Petitioner's Daytime Telephone Number

5.

Applicant's or Petitioner's Email Address (if any)

4.

Applicant's or Petitioner's Mobile Telephone Number (if any)

Applicant's or Petitioner's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any
and all of my records that USCIS may need to determine my suitability and eligibility as an adoptive parent.
I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records; to
other entities and persons where necessary for the administration of U.S. immigration laws.
I certify, under penalty of perjury, that the information in my supplement and any document submitted with my supplement is
complete, true, and correct.

Applicant's or Petitioner's Signature
6.

Applicant's or Petitioner's Signature

Date of Signature
(mm/dd/yyyy)

Part 6. Interpreter's Name, Contact Information, Certification, and Signature
If the adult member of the household and/or applicant or petitioner used an interpreter, the interpreter must provide the following
information:

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name (if any)

Form I-600A/I-600 Supplement 1 02/01/15 N

Interpreter's Given Name (First Name)

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Part 6. Interpreter's Name, Contact Information, Certification, and Signature (continued)
Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

Interpreter's Certification
I certify that:
I am fluent in English and

.

I have read to this adult member of the household and/or applicant or petitioner every question and instruction on this supplement, as
well as the answer to every question in the language in which he and/or she is fluent; and
The adult member of the household and/or applicant or petitioner has informed me that he and/or she understands every instruction
and question on the supplement, as well as his and/or her answers to every question, and the adult member of the household and/or
applicant or petitioner verified the accuracy of every answer.

Interpreter's Signature
6.

Interpreter's Signature

Date of Signature
(mm/dd/yyyy)

Part 7. Name, Contact Information, Statement, Certification, and Signature of the Person Preparing
this Supplement, If Other Than the Adult Member of the Household, and/or Applicant or Petitioner
If the adult member of the household and/or applicant or petitioner used a preparer to complete this supplement, the preparer must
provide the following information:

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name (if any)

Form I-600A/I-600 Supplement 1 02/01/15 N

Preparer's Given Name (First Name)

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Part 7. Name, Contact Information, Statement, Certification, and Signature of the Person Preparing
this Supplement, If Other Than the Adult Member of the Household, and/or Applicant or Petitioner
(continued)
Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Fax Number (if any)

Preparer's Statement
7.A.

I am not an attorney or accredited representative but have prepared this supplement on behalf of the adult member of the
household and/or applicant or petitioner and with the adult member of the household's and/or applicant's or petitioner's
consent.

7.B.

I am an attorney or accredited representative and my representation of the adult member of the household and/or applicant
or petitioner in this case
extends
does not extend beyond the preparation of this supplement.
NOTE: If you are an attorney or accredited representative whose representation extends beyond the preparation of this
supplement, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited
Representative, or Form G-28I, Notice of Entry of Appearance as Attorney in Matters Outside the Geographical Confines of
the United States, with this supplement.

Preparer's Certification
By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this supplement on behalf of, at the request of,
and with the express consent of the adult member of the household and/or applicant or petitioner. I completed this supplement based
only on responses the adult member of the household and/or applicant or petitioner provided to me. After completing the supplement,
I reviewed it and all of the adult member of the household's and/or applicant's or petitioner's responses with the adult member of the
household and/or applicant or petitioner, who agreed with every answer on the supplement. If the adult member of the household and/
or applicant or petitioner supplied additional information concerning a question on the supplement, I recorded it on the supplement.

Preparer's Signature
8.

Preparer's Signature

Date of Signature
(mm/dd/yyyy)

Form I-600A/I-600 Supplement 1 02/01/15 N

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USCIS Privacy Act Statement
AUTHORITY: The information requested on this application, petition, and/or supplement, and the associated evidence, is collected
under Section 101(b)(1)(F) of the Immigration and Nationality Act (INA) [8 USC 1101], 8 CFR 204.3, and 8 CFR 204.311.
PURPOSE: The purpose of Supplement 1 is to collect information on any adult members of the household.
This Supplement must be completed for any individual, other than you and your spouse (if married), who has the same principal
residence as you and is 18 years of age or older on or before the date that Form I-600A or Form I-600 is filed. Residence is defined as
the place of general abode or a person's principal, actual dwelling place in fact, without regard to intent. USCIS reserves the right to
request information on any household member who has not yet reached his or her 18th birthday before the date when Form I-600A or
Form I-600 is filed, or who does not actually live at the same residence, but whose presence in the residence is relevant to the issue of
your and your spouse's suitability to adopt.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested
evidence, may delay a final decision or result in denial of your application or petition.
ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local, and foreign government
agencies and authorized organizations following approved routine uses described in the associated published system of records notices
[DHS/USCIS-005 - Inter-Country Adoptions Security and DHS-USCIS-001 - Alien File, Index, and National File Tracking System of
Records, which can be found at www.dhs.gov/privacy]. The information may also be shared, as appropriate, for law enforcement
purposes or in the interest of national security.

Form I-600A/I-600 Supplement 1 02/01/15 N

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