Form I-600/I-600A Suppl I-600/I-600A Suppl Consent to Disclose Information

Supplement 2,
Consent to Disclose Information

USCIS
Form I-600A/I-600
Supplement 2

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

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

For USCIS Use Only
Remarks

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► START HERE - Type or print in black ink.

Notice

The Privacy Act protects information that U.S. Citizenship and Immigration Services (USCIS) may have concerning your Form
I-600A, Application for Advance Processing of an Orphan Petition, or Form I-600, Petition to Classify Orphan as an Immediate
Relative. See 5 U.S.C. 552a. USCIS generally may not disclose this information without your consent. If you want USCIS to be able
to disclose this information, you may give this consent by signing Form I-600A/I-600, Supplement 2. You are not required to submit
Form I-600A/I-600, Supplement 2, to file Form I-600A or Form I-600.
This supplement does not cover your attorney or accredited representative. In order for USCIS to share information with an individual
who is your legal representative, you must submit 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.
Provide information below about the individual or entity that you are authorizing USCIS to disclose information to. This could
include your home study preparer, the agency that reviewed and approved your home study, your primary adoption service provider,
or any other individual or entity (other than your attorney or accredited representative) to whom USCIS may disclose information.
For more information about home study preparers and primary adoption service providers, see the Instructions for Form I-600A and
Form I-600.
Pursuant to the Privacy Act, 5 USC 552a, and to assist USCIS in adjudicating Form I-600A and/or Form I-600, I (we), the undersigned
applicants/petitioners filing Form I-600A and/or Form I-600, consent to the disclosure of any record pertaining to me (us), which
appears in any system of records maintained by the U.S. Department of Homeland Security (DHS), or which USCIS may obtain as a
result of collecting my (our) biometrics information, to the following individual or entity:
1.

Name of Individual or Entity

3.

Street Number and Name

2.

Point of Contact (contact person within the entity) (if any)

(USPS ZIP Code Lookup)

City or Town

Province

State

Postal Code

4.

Daytime Telephone Number (with area/country code)

6.

Email Address (if any)

Form I-600A/I-600 Supplement 2 12/23/16 N

Apt. Ste. Flr. Number

ZIP Code

Country

5.

Mobile Telephone Number (if any)

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Notice (continued)
I (We) understand that, by signing this supplement, I am (we are) authorizing USCIS to provide the individual or entity named above
with copies of notices sent to me (us) about this case and discuss my (our) case with the individual or entity named in this supplement.
I (We) also understand that an adoption service provider, home study preparer, and home study reviewer can only provide adoption
services and cannot act as my (our) representative before USCIS with respect to my (our) case unless the adoption service
provider/home study preparer is authorized to do so under 8 CFR 292. I (We) also understand that the adoption service provider,
home study preparer, and home study reviewer cannot provide any other legal services unless the adoption service provider/home
study preparer is authorized to do so under the law governing the provision of legal services in the country or state in which the legal
service is provided.

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7.

Your Printed Name

8.

Your Signature

9.

Your Spouse's Printed Name (if you are married)

10. Your Spouse's Signature

Form I-600A/I-600 Supplement 2 12/23/16 N

Date of Signature (mm/dd/yyyy)

Date of Signature (mm/dd/yyyy)

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