Form I-600(A) Supplemen I-600(A) Supplemen Request for Action on Approved Form I-600A/I-600

Supplement 3,
Request for Action on Approved Form I-600A/I-600
Department of Homeland Security
U.S. Citizenship and Immigration Services

Extension Granted to:

For
USCIS
Use
Only

(Date)

USCIS
Form I-600A/I-600
Supplement 3
OMB No. 1615-0028
Expires xx/xx/20xx

Action Block

New Non-Hague country:
(Name of Country)

DRAFT
NOT FOR
PRODUCTION
10/29/2019
Other Change:

(Type of Change)

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

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

Duplicate Approval Notice:
(Date)

Attorney State Bar Number
(if applicable)

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

► START HERE - Type or print in black ink.

If you have changed your marital status since filing your Form I-600A or Form I-600, STOP. Do NOT file this
supplement. Please see the Instructions for Form I-600A, Application for Advance Processing of an Orphan Petition, and Form
I-600, Petition to Classify Orphan as an Immediate Relative, for additional information.

Part 1. Information About You (Applicant/Petitioner who has a valid approved Form I-600A/I-600)
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 7. Additional Information.
Family Name (Last Name)

3.

Date of Birth (mm/dd/yyyy)

4.

City/Town/Village of Birth

Given Name (First Name)

Middle Name (if applicable)

State or Province of Birth

Country of Birth

Your Contact Information
5.

(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/I-600 Supplement 3 12/23/16 N

ZIP Code

Page 1 of 9

Part 1. Information About You (continued)
6.

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

Yes

No

If you answered “No” to Item Number 6., provide the address of your U.S. residence in Item Number 7. or the address for your
residence abroad in Item Number 8., as appropriate.
7.

8.

Address of U.S. Residence (if any)
Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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

Apt. Ste. Flr. Number

City or Town

State

Province

9.

DRAFT
NOT FOR
PRODUCTION
10/29/2019

Street Number and Name

Postal Code

Country

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

Address of Residence Abroad

10. Daytime Telephone Number

11. Mobile Telephone Number (if any)

12. Email Address (if any)

Information About Current Marriage (if applicable)

If you have a new spouse who was not listed on your prior Form I-600A or Form I-600, this is considered a change in marital status.
You cannot use this supplement to report a change in marital status.
13. Is your spouse's name the same as listed on your previously filed Form I-600A or Form I-600?

Yes

No

If you answered “No,” please explain.

14. Is your spouse's address and contact information the same as listed on your previously filed Form I-600A or Form I-600?
Yes

No

If you answered “No,” please explain.

Form I-600A/I-600 Supplement 3 12/23/16 N

Page 2 of 9

Part 2. Action Requested on Your Previously Approved Form I-600A or Form I-600
Provide the following information about your approved Form I-600A or Form I-600.
1.

USCIS Receipt Number (if any)

Date of Approval (mm/dd/yyyy) Date Approval Expires (mm/dd/yyyy)

Location of the Office Where You Filed Your Form I-600A and/or Form I-600

DRAFT
NOT FOR
PRODUCTION
10/29/2019

USCIS Online Account Number (if any)
►
2.

Indicate which of the following item(s) you are requesting. Select all boxes that apply.
A.

A FIRST extension of your Form I-600A. If any changes have occurred, you must indicate such change(s) in Item
Number 3. No Supplement 3 fee is required, but you must submit an updated home study. USCIS will notify you if
you must appear to provide renewed biometrics.

B.

A SECOND or SUBSEQUENT extension of your Form I-600A. If any changes have occurred since your last extension
was granted, indicate such change(s) in Item Number 3. You must submit the Supplement 3 fee and an updated home
study.

C.

A new approval notice based on significant changes since your suitability determination was approved, and you are not
requesting an extension of your suitability determination. You must provide additional details about these changes by
completing Item Number 3. The Supplement 3 fee is required, and you must submit an updated home study.

D.

A FIRST TIME change in your intended adoption country to a new non-Hague Adoption Convention country that was
not previously included in your home study recommendation and suitability determination. You are not requesting an
extension of your suitability determination. No Supplement 3 fee is required, but you must provide the name of the
new non-Hague Adoption Convention country in Item Number 3. and submit an updated home study recommending
adoption in the new non-Hague Adoption Convention country.
If you are requesting both an extension of your approval period and a change of non-Hague Adoption Convention
country, you must also select either Item Number 2.A. or 2.B. and indicate the change in Item Number 3.

E.

A SECOND or SUBSEQUENT change in your intended adoption country to a new non-Hague Adoption Convention
country that was not previously included in your most recent home study recommendation and your most recent
suitability determination. A Supplement 3 fee is required and you must include an updated home study recommending
adoption in the new non-Hague Adoption Convention country.
If you are requesting both an extension of your approval period and a second or subsequent change of non-Hague
Adoption Convention country, you must also select either Item A. or B. in Item Number 2. and indicate the change in
Item Number 3.

F.

A duplicate approval notice. Select this option if you are not requesting an extension and there have been no significant
changes since your suitability determination. A Supplement 3 fee is required.

Form I-600A/I-600 Supplement 3 12/23/16 N

Page 3 of 9

Part 2. Action Requested on Your Previously Approved Form I-600A or Form I-600 (continued)
3.

Provide information on any significant changes that have occurred since your suitability determination was approved or extended.
Your home study preparer must fully explain and evaluate all significant changes in your required home study update. Select all
boxes that apply.
There have been no significant changes.
Change in intended country of adoption to a different non-Hague Adoption Convention country.

DRAFT
NOT FOR
PRODUCTION
10/29/2019

Name of new non-Hague Adoption Convention country

Change of residence, including a change in the child's proposed residence.

Significant decrease in financial resources, such as loss of employment, garnishment of wages, etc.
Change in history of arrest or criminal history for any household member regardless of age.

Change in history of child abuse or neglect, as an offender, for any household member regardless of age.
Change in history of substance abuse, as an offender, for any household member regardless of age.
Change in history of family violence, as an offender, for any household member regardless of age.
Change in history of sexual abuse, as an offender, for any household member regardless of age.

Change in the number and/or identity of children in your household. If you need extra space to complete this section,
use the space provided in Part 7. Additional Information.
Name (First/Middle/Last)

Date of Birth
(mm/dd/yyyy)

Country of Birth

A-Number
(if any)

Relationship to
You (if any)

Change in the number and/or identity of adult members of your household. If you select this box, you must also submit
a Form I-600A/ I-600, Supplement 1, Listing of Adult Member of the Household for each new adult member of your
household.
Change in the number of children or the characteristics (such as age, gender, and/or special needs) of the child or
children you intend to adopt.
A development of a serious health condition for any household member, including but not limited to: heart attacks,
cancer, strokes, conditions requiring extensive therapy, dementia, severe injuries, etc.
Other significant change in your household. (If you select this box, please explain the significant change(s) below. If you
need extra space to complete this section, use the space provided in Part 7. Additional Information.

Form I-600A/I-600 Supplement 3 12/23/16 N

Page 4 of 9

Part 3. Applicant's/Petitioner's Statement, Certification, Duty of Disclosure, and Signature
NOTE: Read the Penalties section of the Form I-600A and Form I-600 Instructions before completing this section.

Applicant's/Petitioner's Statement
1.

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

2.

DRAFT
NOT FOR
PRODUCTION
10/29/2019

The interpreter named in Part 5. read to me every question and instruction on this supplement and my answer to every
question in
, a language in which I am fluent, and I
understood everything.

Applicant's/Petitioner's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 6.,

,

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

Applicant's/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 to adopt and whether the child I am petitioning
for is an orphan and eligible to be classified as my immediate relative.
I furthermore authorize the 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 and enforcement of U.S. immigration law.
I certify, under penalty of perjury under the laws of the United States, that I provided or authorized all of the information in my
supplement, I understand all of the information contained in and submitted with my supplement, and that all of this information is
complete, true, and correct.

Applicant's/Petitioner'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/Petitioner's Signature
3.

Applicant's/Petitioner's Signature

Date of Signature (mm/dd/yyyy)

Part 4. Your Spouse's Statement, Certification, Duty of Disclosure, and Signature
NOTE: Read the Penalties section of the Form I-600A and Form I-600 Instructions before completing this section.

Your Spouse's Statement
1.

Your 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 supplement and
A.
my answer to every question.
B.

The interpreter named in Part 5. 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.

Form I-600A/I-600 Supplement 3 12/23/16 N

Page 5 of 9

Part 4. Your Spouse's Statement, Certification, Duty of Disclosure, and Signature (continued)
2.

Your Spouse's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 6.,
prepared this supplement for me based only upon information I provided or authorized.

,

Your Spouse's Certification

DRAFT
NOT FOR
PRODUCTION
10/29/2019

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 and whether the child my spouse is
petitioning for is an orphan and eligible to be classified as our immediate relative.
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 and enforcement of U.S. immigration law.
I certify under penalty of perjury under the laws of the United States, that I provided or authorized all of the information in this
supplement, I understand all of the information contained in and submitted with this supplement, and that all of this information is
complete, true, and correct.

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-600 and/or I-600A 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)

Part 5. Interpreter's Contact Information, Certification, and Signature

If you and/or your spouse (if married) used an interpreter to read and complete this supplement, 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

Form I-600A/I-600 Supplement 3 12/23/16 N

Postal Code

ZIP Code

Country

Page 6 of 9

Part 5. Interpreter's Contact Information, Certification, and Signature (continued)
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)

DRAFT
NOT FOR
PRODUCTION
10/29/2019

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 3. and/or 4., Item B. in Item Number 1., and I have read to this applicant/petitioner and/or the applicant's/petitioner's spouse in
the identified language every question and instruction on this supplement, and his or her answer to every question. The applicant/
petitioner and/or the applicant's/petitioner's spouse informed me that he or she understands every instruction, question, and answer on
this supplement, including the Applicant's/Petitioner's Certification and the Your Spouse's Certification, and has verified the
accuracy of every answer.

Interpreter's Signature
7.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If
Other Than the Applicant/Petitioner and/or Spouse
If you and/or your spouse (if married) used a preparer to complete this supplement, 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

Form I-600A/I-600 Supplement 3 12/23/16 N

Postal Code

ZIP Code

Country

Page 7 of 9

Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Application, If
Other Than the Applicant/Petitioner and/or Spouse (continued)
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)

DRAFT
NOT FOR
PRODUCTION
10/29/2019

Preparer's Statement
7.

A.

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

B.

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

Preparer's Certification

By my signature, I certify, under penalty of perjury under the laws of the United States, that I prepared this supplement at the request
of the applicant/petitioner and/or the applicant's/petitioner's spouse. The applicant/petitioner and/or the applicant's/petitioner's spouse
then reviewed this completed supplement and informed me that he or she understands all of the information contained in, and
submitted with, his or her supplement, including the Appliant's/Petitioner's Certification and the Your Spouse's Certification, and
that all of this information is complete, true, and correct. I completed this supplement based only on information that the applicant/
petitioner and/or the applicant's/petitioner's spouse provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Form I-600A/I-600 Supplement 3 12/23/16 N

Date of Signature (mm/dd/yyyy)

Page 8 of 9

Part 7. Additional Information
If you need extra space to provide any additional information within this supplement, 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 supplement 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)

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/I-600 Supplement 3 12/23/16 N

Page 9 of 9