Form I-600A Application for advance processing of orphan petition

Application for
Advance Processing of an Orphan Petition

USCIS
Form I-600A

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-0028
Expires 12/31/2018

For USCIS Use Only
The applicant is:
Married

Action Block

Receipt/Fee Stamp

Unmarried

The applicant is approved to adopt an
orphan from (if specified):

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(Name of non-Hague Country)

Remarks

Approval Valid Until (mm/dd/yyyy):

Final Adjudicating Office:

To be Completed by
an Attorney or
Accredited
Representative (if any)

Select this box if
Form G-28 or G-28I
is attached.

Attorney State Bar Number
(if applicable)

Attorney or Accredited Representative
USCIS Online Account Number (if any)

► START HERE - Type or print in black ink. This application is used to determine whether you (and your spouse, if married)
are suitable and eligible to adopt a child from a non-Hague Convention country, who has been or will be adopted and who
qualifies as an orphan under U.S. immigration law.
You must be a U.S. citizen to file this application. See the What Are the Eligibility Requirements section of the Form
I-600A Instructions for more information.

Part 1. Information About You (Applicant)
1.

Family Name (Last Name)

2.

Other Names Used (if any)

Given Name (First Name)

Middle Name (if applicable)

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 12. Additional Information.
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Your Contact Information
3.

(USPS ZIP Code Lookup)

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

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-600A 12/23/16

ZIP Code

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Part 1. Information About You (Applicant) (continued)
4.

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

Yes

No

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

6.

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

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City or Town

State

Address of Residence Abroad (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

7.

Postal Code

ZIP Code

Country

Which address would you like USCIS to use for mailing notices and decisions to you?
U.S. Mailing Address

8.

Apt. Ste. Flr. Number

Address of Residence Abroad

Daytime Telephone Number

9.

Mobile Telephone Number (if any)

10. Email Address (if any)

Information About Your U.S. Citizenship

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

11. USCIS Online Account Number (if any)
►

13. City/Town/Village of Birth

14. State or Province of Birth

15. Country of Birth

16. How did you obtain your U.S. citizenship?

Birth

Parents

Naturalization

A. If you obtained your citizenship through your parents, have you obtained a Certificate of Citizenship in
your own name?

Yes

No

If you answered “Yes,” provide the following information about your Certificate of Citizenship:
Your Name On the Certificate of Citizenship
Family Name (Last Name)

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

Given Name (First Name)

Middle Name (if applicable)

Certificate of Citizenship Number

A-

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Part 1. Information About You (Applicant) (continued)
Date of Issuance (mm/dd/yyyy)

Place of Issuance

B. If you obtained your citizenship through naturalization, provide the following information about your Certificate of
Naturalization:
Your Name On The Certificate of Naturalization
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

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Certificate of Naturalization Number

A-Number (if any)
► A-

Date of Naturalization (mm/dd/yyyy)

Place of Naturalization

17. Have you EVER renounced or lost U.S. citizenship or has anyone you obtained citizenship through
(such as your parent or grandparent) EVER lost U.S. citizenship?

Yes

No

NOTE: If you answered "Yes" to Item Number 17., provide a detailed explanation in the space provided in Part 12. Additional
Information.

Your Duty of Disclosure

You must answer the following questions. See the Duty of Disclosure section in the Form I-600A 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 you under penalty of perjury under U.S. law. The written statement must show the date of each incident; place each
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 would like considered in light of this history.
18. Have you EVER, whether in or outside the United States:

A. Been investigated, arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or
violating any law or ordinance? (Answer “Yes” even if the record of the arrest, conviction, or other
criminal history was expunged, sealed, pardoned, or the subject of any other amelioration. Do not
include parking or traffic violations, except for violations for driving or operating a vehicle while
intoxicated, or while impaired by, or under the influence of, alcohol or another intoxicant.)

Yes

No

B. Received 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 been 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. Been the subject of any investigation at any time even if closed or unsubstantiated, by any child welfare
agency, court, or other official authority in any state or foreign country concerning the abuse or neglect
of any child?

Yes

No

19. What is your marital status?

Single

Married

Separated

Divorced

Widowed

20. How many times have you been married (including your current marriage, if applicable)?

Form I-600A 12/23/16

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Part 2. Information About Your Current Spouse
NOTE: If you are not currently married, skip to Part 3.
1.

Date of Current Marriage (mm/dd/yyyy)

3.

Name of Your Current Spouse

2.

Family Name (Last Name)

4.

Place Where Current Marriage Occurred

Given Name (First Name)

Middle Name (if applicable)

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Other Names Your Current Spouse Has Used

Provide all other names your spouse has ever used, including aliases, maiden name, and nicknames. If you need extra space to
complete this section, use the space provided in Part 12. Additional Information.
Given Name (First Name)

Family Name (Last Name)

5.

Middle Name (if applicable)

Information About Your Current Spouse

Spouse's Date of Birth (mm/dd/yyyy) Spouse's A-Number (if any)

Spouse's USCIS Online Account Number (if any)

► A-

Spouse's City/Town/Village of Birth

►

Spouse's State or Province of Birth

Spouse's Country of Birth

Is your spouse a U.S. citizen?

If you answered “Yes,” how did your spouse obtain citizenship?

Birth

Naturalization

Yes

No

Yes

No

Parents

If you answered “No,” provide your spouse's current U.S. immigration status:

6.

How many times has your current spouse been married (including your current marriage)?

Your Spouse's Contact Information
7.

Does your current spouse reside with you?
If you answered "No," provide your current spouse's physical address in Item Number 8.

8.

Your Current Spouse's Physical Address (if applicable)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-600A 12/23/16

Postal Code

ZIP Code

Country

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Part 2. Information About Your Current Spouse (continued)
9.

Your Spouse's Daytime Telephone Number

10. Your Spouse's Mobile Telephone Number (If any)

11. Your Spouse's Email Address (if any)

Your Spouse's Duty of Disclosure
Your spouse must answer the following questions. See the Duty of Disclosure section in the Form I-600A Instructions concerning
your spouse's ongoing duty to disclose information in response to these questions. If your spouse answers "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 your spouse under penalty of perjury under U.S. law. The written statement
must show the date of each incident; place each 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 your spouse would like considered in light of this
history.

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12. Has your spouse EVER, whether in or outside the United States:

A. Been investigated, arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or
violating any law or ordinance? (Answer “Yes,” even if the record of the arrest, conviction, or other
criminal history was expunged, sealed, pardoned, or the subject of any other amelioration. Do not
include parking or traffic violations, except for violations for driving or operating a vehicle while
intoxicated, or while impaired by, or under the influence of, alcohol or another intoxicant.)

Yes

No

B. Received 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 been 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. Been the subject of any investigation at any time even if closed or unsubstantiated, by any child welfare
agency, court, or other official authority in any state or foreign country concerning the abuse or neglect
of any child?

Yes

No

Part 3. Information About Additional Household Members
1.

How many persons 18 years of age or older (other than your spouse if married) reside with you?

If you answered one or more, you MUST complete Form I-600A/I-600 Supplement 1, Listing of Adult Member of the
Household, for each person.

Form I-600A 12/23/16

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Part 3. Information About Additional Household Members (continued)
2.

List all of your children who are under 18 years of age. Also include any other children under 18 years of age who reside in your
household, regardless of your relationship to those children. If you need extra space to complete this table, use the space provided
in Part 12. Additional Information.
Name (First/Middle/Last)

Date of Birth
(mm/dd/yyyy)

Country of Birth

A-Number
(if any)

Relationship to You

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Part 4. Information About Prior Filings or Adoptions

If you need extra space to complete Item Numbers 1. - 6., use the space provided in Part 12. Additional Information.
1.

Have you ever previously filed Form I-600A; Form I-600, Petition to Classify Orphan as an Immediate
Relative; Form I-800A, Application for Determination of Suitability to Adopt a Child From a Convention
Country; Form I-800, Petition to Classify Convention Adoptee as an Immediate Relative; or Form I-130
Petition for Alien Relative for an adopted child?

Yes

No

If you answered "Yes," provide the following information for EACH petition and/or application:
Type of Petition/Application Filed:
Form I-600A
Result:

Form I-600

Approved

Denied

Form I-800A
Withdrawn

Form I-800

Form I-130 (for an adopted child)

Revoked

Other (please explain):

Date (mm/dd/yyyy)

2.

Have you previously completed a domestic adoption of a child within the U.S.?

Yes

No

If you answered “Yes,” provide the following information for each completed domestic adoption.
State And Country Where Adoption Was Finalized

3.

Date Adoption Was Finalized (mm/dd/yyyy)

Have you ever previously attempted to adopt a child internationally or domestically, but the adoption
was disrupted before it was finalized? An adoption is disrupted if you (or a custodian escorting the child
on your behalf) are granted legal custody or guardianship of the child but the adoptive placement is
interrupted before the adoption was finalized.

Yes

No

If you answered “Yes,” provide a detailed description of the disruption.

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Part 4. Information About Prior Filings or Adoptions (continued)
4.

Have you ever previously completed an adoption, either in the United States or abroad, that was later
dissolved? An adoption is dissolved if your parental rights over the adopted child are terminated at any
time after the adoption was finalized.

Yes

No

Yes

No

If you answered “Yes,” provide a detailed description of the dissolution.

5.

Have you ever previously placed a child in the care of another person with the intent to transfer permanent
custody of the child?

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If you answered “Yes,” provide a detailed description of the placement.

6.

Have you ever received a child with the intent to gain permanent custody but without involving child
welfare or other state/local authorities or following a state/local process?

Yes

No

If you answered “Yes,” provide a detailed description of the custody transfer.

Part 5. Information About Your Home Study Preparer and/or Primary Adoption Service Provider
1.

Your home study:
A.
B.

IS attached to this Form I-600A.

IS NOT attached to this Form I-600A, but will be submitted within one year from the date you file this Form I-600A.
(If your home study is not received within one year, USCIS will deny your Form I-600A under 8 CFR 204.3(c)(2) and
(h)(5).)

Information About Your Home Study Preparer
2.

Information About Who Prepared or Will Prepare Your Home Study
A. Name of Home Study Preparer

B. Point of Contact Within the Organization (if applicable)
Family Name (Last Name)

Given Name (First Name)

C. Home Study Preparer's Mailing Address and Contact Information
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Form I-600A 12/23/16

Postal Code

ZIP Code

Country

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Part 5. Information About Your Home Study Preparer and/or Primary Adoption Service Provider
(continued)
D. Home Study Preparer's Daytime Telephone Number

E. Home Study Preparer's Fax Number (if any)

F. Home Study Preparer's Email Address (if any)

Information About Your Home Study Reviewer and Approver (if applicable)

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If your home study was not performed by an accredited agency, an accredited agency must review and approve your home study
before you submit it to USCIS. This requirement does not apply to a home study that was prepared by a public domestic authority or a
public foreign authority.
3.

Information About Who Reviewed And Approved (or will review and approve) Your Home Study (if applicable)
A. Name of Home Study Reviewer/Approver

B. Point of Contact Within the Organization (if applicable)
Family Name (Last Name)

Given Name (First Name)

C. Reviewer's/Approver's Mailing Address and Contact Information
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

D. Home Study Reviewer's/Approver's Daytime Telephone
Number

ZIP Code

Country

E. Home Study Reviewer's/Approver's Fax Number
(if any)

F. Home Study Reviewer's/Approver's Email Address (if any)

Information About Your Primary Adoption Service Provider (if applicable)
A primary adoption service provider is the accredited agency or approved person who is responsible under 22 CFR 96 for ensuring all
six adoption services defined in 22 CFR 96.2 are provided according to the law, for supervising and being responsible for supervised
providers when used (see 22 CFR 96.14), and for developing and implementing a service plan in accordance with 22 CFR 96.44.
4.

Is your home study preparer or the agency that reviewed and approved your home study also your primary
adoption service provider?

Yes

No

If you answered “Yes,” indicate which individual or organization provided in either Item Number 2. or Item Number 3. is
serving as your primary adoption service provider.

If you answered “No” to Item Number 4., you must answer Item Number 5.

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Part 5. Information About Your Home Study Preparer and/or Primary Adoption Service Provider
(continued)
5.

Have you identified another accredited agency or approved person to serve as your primary adoption service provider?
Yes, I have identified a primary adoption service provider that will be responsible for my case. Provide the name and contact
information of your primary adoption service provider in Item A. below.
No, I have not yet identified a primary adoption service provider that will be responsible for my case.
NOTE: If, during the adoption process, you do not identify a different agency to serve as your primary adoption service
provider, the individual or agency that prepared or reviewed and approved your home study must serve as your primary
adoption service provider when you file your Form I-600 petition on behalf of a specific child. See the General Instructions
section of the Form I-600A's Instructions for more information.

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Provide the name and contact information of the primary adoption service provider that will be responsible for your case.
A. Name of Primary Adoption Service Provider

B. Point of Contact Within the Organization
Family Name (Last Name)

Given Name (First Name)

C. Primary Adoption Service Provider's
Mailing Address

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

D. Primary Adoption Service Provider's Daytime Telephone
Number

ZIP Code

Country

E. Primary Adoption Service Provider's Fax Number
(if any)

F. Primary Adoption Service Provider's Email Address
(if any)

6.

The primary adoption service provider named above is one of the following:
A. An accredited agency in the United States.

Yes

No

B. An approved person in the United States.

Yes

No

Yes

No

Part 6. Information About Your Intended Adoption(s)
1.

What country do you intend to adopt from (if known)?

2.

Do you or your spouse (if married) plan to travel abroad to locate or adopt a child?

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Part 6. Information About Your Intended Adoption(s) (continued)
3.

If you answered “Yes” to Item Number 2., provide the following information (if available):
B. Your Spouse's Intended Departure Date
(mm/dd/yyyy)

A. Your Intended Departure Date
(mm/dd/yyyy)

C. Place to Which You or Your Spouse (if married) Are Traveling
Province

City or Town

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Country

4.

Will you and your spouse (if married) adopt the child abroad after either you or your spouse (if married)
have personally seen and observed the child before or during the adoption proceedings?

5.

If you know that the child will be adopted in the United States, provide a written description of all the pre-adoption requirements
of the state of the child's proposed residence. Cite any relevant state statutes and regulations, and describe the steps you have
already taken or will take to comply with these requirements. Identify and explain any pre-adoption requirements that you
cannot meet at this time as a result of state law. If you need extra space to complete this Item Number., use the space provided
in Part 12. Additional Information.

6.

Where do you wish to file your Form I-600 orphan petition? (Complete one of the options below)

Yes

No

A. The USCIS office located at:
OR

B. The U.S. Embassy or U.S. Consulate located at:
7.

Do you plan to adopt more than one child?

8.

If you answered “Yes,” enter the number of children you plan to adopt.

Yes

No

Yes

No

Part 7. Accommodations for Individuals With Disabilities and/or Impairments
NOTE: Read the information in the Form I-600A Instructions before completing this section.
1.

Are you requesting an accommodation because of disabilities and/or impairments?

2.

If you answered “Yes,” select all applicable boxes below that indicate who has the disabilities and/or impairments.
Applicant

3.

Spouse

Adult Member of the Household

If you answered “Yes” to Item Number 1., select all applicable boxes in Items A. - C. and provide an answer for each person
with disabilities and/or impairments.
A.

Deaf or hard of hearing and request the following accommodation. (If requesting a sign-language interpreter, indicate
for which language (for example, American Sign Language)):

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Part 7. Accommodations for Individuals With Disabilities and/or Impairments (continued)
B.

Blind or have low vision and request the following accommodation:

C.

Another type of disability and/or impairment. (Describe the nature of the disability and/or impairment and the requested
accommodation):

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Part 8. Applicant's Statement, Certification, Duty of Disclosure, and Signature
NOTE: Read the Penalties section of the Form I-600A Instructions before completing this section.

Applicant's Statement
1.

Applicant's Statement Regarding the Interpreter (select the box for either Item A. or B.)
A.
I can read and understand English, and I have read and understand every question and instruction on this application and
my answer to every question.
B.

2.

The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am fluent, and I
understood everything.

Applicant's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 11.,

,

prepared this application for me based only upon information I provided or authorized.

Applicant'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 to adopt.
I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the administration and enforcement of U.S. immigration law.
I understand that USCIS will require me to appear for an appointment to take my biometrics (for example, fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my application;
2) I understood all of the information contained in, and submitted with, my application; and
3) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury under the laws of the United States, that I provided or authorized all of the information in my
application, I understand all of the information contained in and submitted with my application, and that all of this information is
complete, true, and correct.

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Part 8. Applicant's Statement, Certification, Duty of Disclosure, and Signature (continued)
Applicant's Duty of Disclosure
I understand the ongoing duty to disclose information concerning my suitability and eligibility to adopt, as described in the Form
I-600A and/or Form I-600 Instructions, and I agree to notify my home study preparer and USCIS of any new information that I am
required to disclose.

Applicant's Signature
3.

Applicant's Signature

Date of Signature (mm/dd/yyyy)

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NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.

Part 9. Your Spouse's Statement, Certification, Duty of Disclosure, and Signature
Your Spouse's Statement
1.

Spouse's Statement Regarding the Interpreter (select the box for either Item A. or B.)
I can read and understand English, and have read and understand every question and instruction on this application and
A.
my answer to every question.
B.

2.

The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am fluent, and I
understood everything.

Spouse's Statement Regarding the Preparer (if applicable)

At my request, the preparer named in Part 11.,
prepared this application for me based only upon information I provided or authorized.

,

Your Spouse'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 to adopt.
I furthermore authorize release of information contained in this application, in supporting documents, and in my USCIS records, to
other entities and persons where necessary for the administration and enforcement of U.S. immigration law.
I understand that USCIS will require me to appear for an appointment to take my biometrics (for example, fingerprints, photograph,
and/or signature) and, at that time, I will be required to sign an oath reaffirming that:
1) I reviewed and provided or authorized all of the information in my application;
2) I understood all of the information contained in, and submitted with, my application; and
3) All of this information was complete, true, and correct at the time of filing.
I certify, under penalty of perjury under the laws of the United States, that I provided or authorized all of the information in my
application, I understand all of the information contained in and submitted with my application, and that all of this information is
complete, true, and correct.

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Part 9. Your Spouse's Statement, Certification, Duty of Disclosure, and Signature (continued)
Your Spouse's Duty of Disclosure
I understand the ongoing duty to disclose information concerning my suitability and eligibility to adopt, as described in the Form
I-600A and/or Form I-600 Instructions, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.

Your Spouse's Signature
3.

Your Spouse's Signature

Date of Signature (mm/dd/yyyy)

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Part 10. Interpreter's Contact Information, Certification, and Signature

If you and/or your spouse (if married) used an interpreter to read and complete this application, provide the following information
about the interpreter.

Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

Interpreter's Given Name (First Name)

2.

Interpreter's Business or Organization Name (if any)

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

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury under the laws of the United States, that:
I am fluent in English and

,which is the same language specified in

Part 8. and/or 9., Item B. in Item Number 1., and I have read to this applicant and/or the applicant's spouse in the identified language
every question and instruction on this application and his or her answer to every question. The applicant and/or the applicant's spouse
informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's
Certification and the Your Spouse's Certification, and has verified the accuracy of every answer.

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Part 10. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Signature
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, If
Other Than the Applicant and Spouse

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If you and/or your spouse (if married) used a preparer to complete this application, provide the following information about the
preparer.

Preparer's Full Name
1.

Preparer's Family Name (Last Name)

Preparer's Given Name (First Name)

2.

Preparer's Business or Organization Name (if any)

Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

ZIP Code

Country

Postal Code

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (if any)

Preparer's Statement
7.

A.

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and/or the
applicant's spouse with the applicant's and/or the applicant's spouse's (if married) consent.

B.

I am an attorney or accredited representative and my representation of the applicant and/or the applicant's spouse in
this case
extends
does not extend beyond the preparation of this application.

Form I-600A 12/23/16

Page 14 of 16

Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, If
Other Than the Applicant and Spouse (continued)
Preparer's Certification
By my signature, I certify, under penalty of perjury under the laws of the United States, that I prepared this application at the request
of the applicant and/or the applicant's spouse. The applicant and the applicant's spouse then reviewed this completed application and
informed me that he or she understands all of the information contained in, and submitted with, his or her application, including the
Applicant's Certification and the Your Spouse's Certification, and that all of this information is complete, true, and correct. I
completed this application based only upon information that the applicant and/or the applicant's spouse provided to me or authorized
me to obtain or use.

Fee Rule DRAFT
NOT FOR
PRODUCTION
10/29/2019

Preparer's Signature
8.

Preparer's Signature

Form I-600A 12/23/16

Date of Signature (mm/dd/yyyy)

Page 15 of 16

Part 12. Additional Information
If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
If you attach a separate sheet of paper, type or print your full 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.
1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

5.

A. Page Number

D.

6.

Middle Name (if applicable)

Fee Rule DRAFT
NOT FOR
PRODUCTION
10/29/2019

A. Page Number

D.

Given Name (First Name)

A. Page Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

Form I-600A 12/23/16

Page 16 of 16