Form I-600/I-600A Suppl I-600/I-600A Suppl Listing of Adult Member of the Household

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 12/31/2021

► START HERE - Type or print in black ink. You, the applicant or petitioner, must complete Form I-600A/Form I-600,
Supplement 1, for EACH adult member of your household 18 years of age or older. Do not complete this supplement for yourself or
your spouse (if married).
Answer all questions fully and accurately. If a question does not apply to you (for example, if you have never been married and the
question asks, “Provide the name of your current spouse”), type or print “N/A” unless otherwise directed. If your answer to a question
which requires a numeric response is zero or none (for example, “How many children do you have?” or “How many times have you
departed the United States?”), type or print “None” unless otherwise directed.

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Part 1. Information About an Adult Member of the Household

Provide the following information about the Adult Member of the Household.
1.

Family Name (Last Name)

2.

Other Names the Adult Member of the Household Has Used

Given Name (First Name)

Middle Name

Provide all other names the adult member of the household has 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)

Given Name (First Name)

Middle Name

Adult Member of the Household's Contact Information
3.

U.S. Mailing Address

(USPS ZIP Code Lookup)

In Care Of Name

4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Is the current U.S. mailing address the same address as the adult member of the household's physical residence?

Yes

No

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

Address of U.S. Residence
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-600A/I-600 Supplement 1 12/21/19

ZIP Code

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Part 1. Information About an Adult Member of the Household (continued)
6.

Address of Residence Abroad
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

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7.

Daytime Telephone Number

9.

Email Address

Postal Code

Country

8.

Mobile Telephone Number

Adult Member of the Household's Biographical Information
10. Date of Birth (mm/dd/yyyy)

11. City/Town/Village of Birth

12. State or Province of Birth

14. Alien Registration Number (A-Number)
►

A-

13. Country of Birth

15. USCIS Online Account Number
►

Duty of Disclosure

You, the applicant or petitioner, 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. The written statement must be signed by the adult member of the household under penalty
of perjury under U.S. law.
The written statement must also show the date of each incident; place each incident occurred (city/town, state/province, country);
name of the police department or other law enforcement administration or other entity involved; and date of incarceration and name of
facility; and include your (the applicant's/petitioner's) name and A-Number at the top of each sheet. In your written statement, you
should also 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.
16. Has the adult member of the household 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 in an alternative sentencing or
rehabilitation program, such as diversion, deferred prosecution, deferred or withheld adjudication, or
expungement of a criminal charge?

Yes

No

Form I-600A/I-600 Supplement 1 12/21/19

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Part 1. Information About an Adult Member of the Household (continued)
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 2. Adult Member of the Household's Statement, Certification, Duty of Disclosure, and Signature

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Notice to the Adult Member of the Household: By signing this Form I-600A/I-600, Supplement 1, you agree that U.S. Citizenship and
Immigration Services (USCIS) may disclose to the applicant/petitioner or the applicant's/petitioner's adoption service providers
information that USCIS may obtain about you that is relevant to the adjudication of the applicant's Form I-600A or petitioner's Form
I-600, even if the Privacy Act, 5 USC 552a, might otherwise prevent disclosure of the information without your consent.
NOTE: If you, an adult member of the household, knowingly and willfully falsify or conceal a material fact or submit a false
document in support of this Supplement 1, USCIS will deny the Form I-600A or Form I-600 filed for this case and may deny any
other USCIS benefits requested by the prospective adoptive parents.

Adult Member of the Household's Statement
1.

Adult Member of the Household'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 supplement and
my answer to every question.

B.

The interpreter named in Part 5. has 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.
2.

Adult Member of the Household'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.

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/petitioner to adopt.
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 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 this supplement;

2)

I understood all of the information contained in, and submitted with, this supplement; 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 this
supplement, I understand all of the information contained in, and submitted with, this this supplement, and that all of this information
is complete, true, and correct.

Adult Member of the Household's Duty of Disclosure
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, home study preparer, and USCIS of any new information that I
am required to disclose.
Form I-600A/I-600 Supplement 1 12/21/19

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Part 2. Adult Member of the Household's Statement, Certification, Duty of Disclosure, and Signature
(continued)
Adult Member of the Household's Signature
3.

Adult Member of the Household's Signature

Date of Signature (mm/dd/yyyy)

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Part 3. Information About You, the Applicant/Petitioner
1.

Family Name (Last Name)

2.

Date of Birth (mm/dd/yyyy)

4.

State or Province of Birth

6.

A-Number
►

8.

A-

Given Name (First Name)

3.

Middle Name

City/Town/Village of Birth

Mobile Telephone Number

5.

7.

Country of Birth

Daytime Telephone Number

9.

Email Address

10. USCIS Online Account Number
►

Part 4. Applicant's/Petitioner's Statement, Certification, and Signature

NOTE: If you or any adult member of your household knowingly and willfully falsify or conceal a material fact or submit a false
document with your Supplement 1, USCIS will deny your Form I-600A or Form I-600 and may deny any USCIS benefit you request.

Applicant's/Petitioner's Statement
1.

Applicant's/Petitioner'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 supplement and
my answer to every question.

B.

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.

2.

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.

Form I-600A/I-600 Supplement 1 12/21/19

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Part 4. Applicant's/Petitioner's Statement, Certification, and Signature (continued)
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.

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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 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 Signature
3.

Applicant's/Petitioner's Signature

Date of Signature (mm/dd/yyyy)

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

If the adult member of the household and/or the applicant/petitioner 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

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

Form I-600A/I-600 Supplement 1 12/21/19

5.

Interpreter's Mobile Telephone Number (if any)

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

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2. and/or 4., Item B. in Item Number 1., and I have read to this adult member of the household and/or the applicant/petitioner in the
identified language every question and instruction on this supplement and his or her answer to every question. The adult member of
the household and/or the applicant/petitioner informed me that he or she understands every instruction, question, and answer on the
supplement, including the Adult Member of the Household's Certification and the Applicant's/Petitioner'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 Supplement, If
Other Than the Applicant/Petitioner or Adult Member of the Household
If the adult member of the household and/or the applicant/petitioner 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

Postal Code

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

Form I-600A/I-600 Supplement 1 12/21/19

5.

Preparer's Mobile Telephone Number (if any)

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Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Supplement, If
Other Than the Applicant/Petitioner or Adult Member of the Household (continued)
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 the applicant/petitioner with the adult member of the household's and/or the applicant's/petitioner's
consent.

B.

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

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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 adult member of the household and/or the applicant/petitioner. The adult member of the household and/or the applicant/
petitioner then reviewed this completed supplement and informed me that he or she understands all of the information contained in,
and submitted with, this supplement, including the Adult Member of the Household's Certification and the Applicant's/
Petitioner's Certification, and that all of this information is complete, true, and correct. I completed this supplement based only on
information that the adult member of the household and/or the applicant/petitioner provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Form I-600A/I-600 Supplement 1 12/21/19

Date of Signature (mm/dd/yyyy)

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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 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

3.

A. Page Number

D.

4.

5.

Middle Name

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A. Page Number

D.

Given Name (First Name)

A. Page Number

► A-

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.

6.

A. Page Number

D.

Form I-600A/I-600 Supplement 1 12/21/19

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DHS Privacy Notice
AUTHORITIES: The information requested on this supplement, and the associated evidence, is collected under the Immigration and
Nationality Act sections 101(b)(1)(F), 201, and 204, and 8 CFR sections 204.3, 204.301, and 204.311.
PURPOSE: This supplement must be completed for every adult member of the household, other than the applicant/petitioner and
spouse (if married). USCIS may request submission of this supplemental form for additional individuals. The purpose of this
supplement is to collect information on any individual who has the same residence as the applicant/petitioner and is 18 years of age or
older on or before the date the applicant/petitioner files Form I-600A or Form I-600, any household member who has not yet turned 18
years of age before the applicant/petitioner files Form I-600A or Form I-600, and any individual who does not actually live at the
same residence as the applicant/petitioner, but whose presence USCIS deems relevant to determine the applicant/petitioner's suitability
to adopt. USCIS will determine suitability by conducting background and security checks on adult household members to assist in
assessing the suitability of the applicant/petitioner.

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DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your
Social Security number (if applicable), and any requested evidence, may delay a final decision or result in a rejection or denial of the
underlying adoption-related application and/or petition.
ROUTINE USES: The Department of Homeland Security (DHS) may share the information you provide on this supplement and any
additional requested evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS
follows approved routine uses described in the associated published system of records notices [DHS-USCIS-001 - Alien File, Index,
and National File Tracking System of Records, DHS-USCIS-005 - Inter-Country Adoptions Security, and DHS/USCIS-018
Immigration and Biometric and Background Check] and the published privacy impact assessments [DHS/USCIS/PIA-007(b)
Domestically Filed Intercountry Adoptions Applications and Petitions and DHS/USCIS/PIA-051 Case and Activity Management for
International Operations] which you can find at www.dhs.gov/privacy. DHS may also share this information, as appropriate, for law
enforcement purposes or in the interest of national security.
PRIVACY ACT WAIVER: Except as permitted by the Privacy Act, 5 U.S.C. 552a, applicable routine uses, and information related
to adult members of your household as noted below, USCIS may not disclose or give access to any information or record relating to
any applicant/petitioner, spouse (if married), or adult member of your household to any individual or entity other than that person,
including but not limited to an accredited agency, approved person, exempted provider, supervised provider, or other adoption service
provider, unless you give written consent.
If you want to give consent for USCIS to disclose information about your case to an individual or entity, you must complete Form
I-600A/I-600, Supplement 2, Consent to Disclose Information. You are not required to give this consent to file Form I-600.
NOTICE TO ADULT MEMBERS OF THE HOUSEHOLD: You are not the prospective adoptive parent who is filing Form
I-600A application or Form I-600 petition. As an adult member of the prospective adoptive parent's household, however, information
about you may be relevant to the adjudication of the prospective adoptive parent's Form I-600A or Form I-600. Under
8 CFR 103.2(b)(16), the prospective adoptive parent is entitled to review any information that may be used to deny a Form I-600A or
Form I-600. By signing the Form I-600A/Form I-600, Supplement 1, you consent to USCIS disclosing to the prospective adoptive
parents, adoption service provider, home study preparer, if applicable, and any individual or entity identified by the prospective
adoptive parent, if applicable, information that USCIS may obtain about you that is relevant to the adjudication of the prospective
adoptive parent's Form I-600 or Form I-600A, even if the Privacy Act, 5 U.S.C. 552a, might otherwise prevent disclosure of the
information to the prospective adoptive parents.

Form I-600A/I-600 Supplement 1 12/21/19

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