TABLE OF CHANGES – Form
Form I-600A, Application for Advance Processing of an Orphan Petition
OMB Number: 1615-0028
05/28/2020
Reason for Revision: Fee Rule Final Rule. Project Phase: G-1056
Legend for Proposed Text:
Expires 12/31/2021 Edition Date 12/21/2019 |
Current Page Number and Section |
Current Text |
Proposed Text |
Page 1, For USCIS Use Only |
[Page 1]
For USCIS Use Only
The applicant is: Married Unmarried
The applicant is approved to adopt an orphan from (if specified): [Fillable Field] (Name of non-Hague Convention Country) Approval Valid Until: Final Adjudicating Office:
Action Block
Receipt/Fee Stamp
Remarks
To be Completed by an Attorney or Accredited Representative (if any) Select this box if Form G-28 or Form G-28I is attached. Attorney State Bar Number (if applicable): Attorney or Accredited Representative USCIS Online Account Number (if any)
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[Page 1]
For USCIS Use Only
The applicant is: Married Unmarried
The applicant is approved to adopt an orphan from (if specified): [Fillable Field] (Name of non-Hague Country) Approval Valid Until: Final Adjudicating Office:
Action Block
Receipt/Fee Stamp
Remarks
To be Completed by an Attorney or Accredited Representative Select this box if Form G-28 or Form G-28I is attached. Attorney State Bar Number: Attorney or Accredited Representative USCIS Online Account Number
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Pages 1-6,
Part 1. Information About You (Applicant)
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[Page 1]
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 in order to file this application. See the What Are the Eligibility Requirements section of the Form I-600A Instructions for more information.
1. Family Name (Last
Name) 2. Other Names Used (if any)
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 9. Additional Information.
Family Name (Last Name) Your Contact Information
3. U.S. Mailing Address (if
any) Number
[Page 2]
4. Is your current U.S. mailing address the same as your U.S. physical address? Yes No
If you answered "No," provide your U.S. physical address in Item Number 5. or your address abroad in Item Number 6., as appropriate.
5. U.S. Physical Address (if
any)
6. Address Abroad (if
any)
7. Daytime Telephone Number 8. Mobile Telephone Number (if any) 9. Email Address (if any)
10. USCIS Online Account Number (if any)
11. Date of Birth
(mm/dd/yyyy) 12. City/Town/Village of
Birth 13. State or Province of
Birth 14. Country of Birth
15. How did you obtain your
U.S. citizenship? A. If you obtained your citizenship through your parents, have you obtained a Certificate of Citizenship or Certificate of Naturalization 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 or Certificate of Naturalization Family Name (Last Name)
[Page 3]
B. If you obtained your citizenship through naturalization, provide the following information about your Certificate of Naturalization:
Your Name On The Certificate of
Naturalization
16. 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,” provide a detailed explanation in the space provided in Part 9. Additional Information.
17. What is your marital
status? Married Separated Divorced Widowed
18. How many times have you been married (including your current marriage, if applicable)?
[content moved from later in this Part]
NOTE: If you are not
currently married, skip to Item Number 30. Information About Your Current Marriage
19. Date of Current Marriage (mm/dd/yyyy)
20. Place Where Current Marriage Occurred
21. Name of Your Current Spouse
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 9. Additional Information.
Family Name (Last Name)
23. Information About Your Current Spouse
Spouse’s USCIS Online Account
Number (if any)
[Page 4]
Spouse’s City/Town/Village of
Birth
If you answered “Yes,” how did your spouse obtain citizenship? Birth Naturalization Parents
If you answered “No,”
provide your spouse’s current U.S. immigration status: 24. How many times has your current spouse been married (including your current marriage, if applicable)?
25. Does your current spouse reside with you? Yes No
26. Your Current Spouse's
Physical Address (if applicable) State
27. Your Spouse’s Daytime Telephone Number 28. Your Spouse’s Mobile Telephone Number (if any) 29. Your Spouse’s Email Address (if any)
Additional Household Members
30. How many persons 18 years of age or older (other than your spouse if married) reside with you?
If you answered "1" or more, you MUST complete Form I-600A/I-600 Supplement 1, Listing of Adult Member of the Household, for each person.
[Page 5]
31. 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 9. Additional Information.
[Table 5 entries] Name (First/Middle/Last) Date of Birth (mm/dd/yyyy) Country of Birth A-Number (if any) Relationship to You (if any)
Information About Prior Filings or Adoptions
If you need extra space to complete Item Numbers 32. - 37., use the space provided in Part 9. Additional Information.
32. 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, or Form
I-800, Petition to Classify Convention Adoptee as an Immediate
Relative? Yes No If you
answered "Yes," provide the following
information for EACH petition and/or application: Type of Application/Petition Filed: Form I-600A Form I-600 Form I-800A Form I-800 Form I-130 (for an adopted child)
Result: Approved Denied Withdrawn Revoked Other (please explain): [fillable field] Date (mm/dd/yyyy)
33. 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 of a child.
State And Country Where Adoption Was Finalized
Date Adoption Was Finalized (mm/dd/yyyy)
34. 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. [Fillable field]
[Page 6]
35. 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
If you answered “Yes,” provide a detailed description of the dissolution. [Fillable field]
36. Have you ever previously placed a child in the care of another person with the intent to transfer permanent custody of the child? Yes No
If you answered “Yes,” provide a detailed description of the placement. [Fillable field]
37. 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 the state/local process? Yes No
If you answered “Yes,” provide a detailed description of the custody transfer. [Fillable field]
You and your spouse (if married), 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 or your spouse answer "Yes" to any of the questions in Item Numbers 38. and 39., 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 and/or your spouse (if married) 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; date of incarceration and name of facility, if applicable. Provide a description of any type of counseling, rehabilitation, or other information that you and your spouse (if married) would like considered in light of this history in the space provided in Part 9. Additional Information.
38. 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 adverse criminal history was expunged, sealed, pardoned, or the subject of any other amelioration. Do not include traffic violations, except for violations for driving or operating a vehicle while intoxicated or while impaired by or under the influence of alcohol or other 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
39. 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 adverse criminal history was expunged,
sealed, pardoned, or the subject of any other amelioration. Do
not include traffic violations, except for violations for driving
or operating a vehicle while intoxicated or while impaired by or
under the influence of alcohol or other intoxicant.) Yes No
[Page 7]
B. Received 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 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
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[Page 1]
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.
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.
1. Family Name (Last
Name) 2. Other Names Used
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) Your Contact Information
3. U.S. Mailing Address
Number
[Page 2]
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. Address
of U.S. Physical Residence
6. Address of
Residence Abroad
7. Which address would you like USCIS to use for mailing notices and decisions to you? [] U.S. Mailing Address [] Address of
Residence Abroad 8. Daytime Telephone Number 9. Mobile Telephone Number 10. Email Address
11. USCIS Online Account Number
12.
Date of Birth (mm/dd/yyyy) 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? A. If you obtained your citizenship through your parents, have you obtained a Certificate of Citizenship or Certificate of Naturalization 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 or Certificate of Naturalization Family Name (Last Name)
[Page 3]
B. If you obtained your citizenship through naturalization, provide the following information about your Certificate of Naturalization:
Your Name On The Certificate 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. 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? Married Separated Divorced Widowed
20. How many times have you been married (including your current marriage, if applicable)?
[rest of content moved into new Parts]
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New |
[taken from Part 1]
Information About Your Current Marriage
19. Date of Current Marriage (mm/dd/yyyy)
20. Place Where Current Marriage Occurred
21. Name of Your Current Spouse
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 9. Additional Information.
Family Name (Last Name)
23. Information About Your Current Spouse
Spouse’s USCIS Online Account
Number (if any)
[Page 4]
Spouse’s City/Town/Village of
Birth
If you answered “Yes,” how did your spouse obtain citizenship? Birth Naturalization Parents
If you answered “No,”
provide your spouse’s current U.S. immigration status: 24. How many times has your current spouse been married (including your current marriage, if applicable)?
25. Does your current spouse reside with you? Yes No
26. Your Current Spouse's
Physical Address (if applicable) State
27. Your Spouse’s Daytime Telephone Number 28. Your Spouse’s Mobile Telephone Number (if any) 29. Your Spouse’s Email Address (if any)
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[Page 4]
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)
2. Place Where Current Marriage Occurred
3. Name of Your Current Spouse
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.
Family Name (Last Name)
5. Information About Your Current Spouse
Spouse’s USCIS Online Account
Number
Spouse’s City/Town/Village of
Birth
If you answered “Yes,” how did your spouse obtain citizenship? Birth Naturalization 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)?
7. Does your current spouse reside with you? Yes No
8. Your Current Spouse's Physical Address
State
[Page 5]
9. Your Spouse’s Daytime Telephone Number 10. Your Spouse’s Mobile Telephone Number
11. Your Spouse’s Email Address
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. Provide a description of any type of counseling, rehabilitation, or other information that your spouse would like considered in light of this history.
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
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New |
[taken from Part 1]
Additional Household Members
30. How many persons 18 years of age or older (other than your spouse if married) reside with you?
If you answered "1" or more, you MUST complete Form I-600A/I-600 Supplement 1, Listing of Adult Member of the Household, for each person.
[Page 5]
31. 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 9. Additional Information.
[Table 5 entries] Name (First/Middle/Last) Date of Birth (mm/dd/yyyy) Country of Birth A-Number (if any) Relationship to You (if any)
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[Page 5]
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.
[Page 6]
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.
[Table 5 entries] Name (First/Middle/Last) Date of Birth (mm/dd/yyyy) Country of Birth A-Number Relationship to You
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New |
[taken from Part 1]
Information About Prior Filings or Adoptions
If you need extra space to complete Item Numbers 32. - 37., use the space provided in Part 9. Additional Information.
32. 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, or Form
I-800, Petition to Classify Convention Adoptee as an Immediate
Relative? Yes No
If you
answered "Yes," provide the following
information for EACH petition and/or application: Type of Application/Petition Filed: Form I-600A Form I-600 Form I-800A Form I-800 Form I-130 (for an adopted child)
Result: Approved Denied Withdrawn Revoked Other (please explain): [fillable field] Date (mm/dd/yyyy)
33. 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 of a child.
State And Country Where Adoption Was Finalized
Date Adoption Was Finalized (mm/dd/yyyy)
34. 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. [Fillable field]
[Page 6]
35. 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
If you answered “Yes,” provide a detailed description of the dissolution. [Fillable field]
36. Have you ever previously placed a child in the care of another person with the intent to transfer permanent custody of the child? Yes No
If you answered “Yes,” provide a detailed description of the placement. [Fillable field]
37. 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 the state/local process? Yes No
If you answered “Yes,” provide a detailed description of the custody transfer. [Fillable field]
You and your spouse (if married), 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 or your spouse answer "Yes" to any of the questions in Item Numbers 38. and 39., 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 and/or your spouse (if married) 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; date of incarceration and name of facility, if applicable. Provide a description of any type of counseling, rehabilitation, or other information that you and your spouse (if married) would like considered in light of this history in the space provided in Part 9. Additional Information.
38. 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 adverse criminal history was expunged, sealed, pardoned, or the subject of any other amelioration. Do not include traffic violations, except for violations for driving or operating a vehicle while intoxicated or while impaired by or under the influence of alcohol or other 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
39. 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 adverse criminal history was expunged,
sealed, pardoned, or the subject of any other amelioration. Do
not include traffic violations, except for violations for driving
or operating a vehicle while intoxicated or while impaired by or
under the influence of alcohol or other intoxicant.) Yes No
[Page 7]
B. Received 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 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
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[Page 6]
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 Application/Petition Filed: Form I-600A Form I-600 Form I-800A Form I-800 Form I-130 (for an adopted child)
Result: Approved Denied Withdrawn Revoked Other (please explain): [fillable field] 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
Date Adoption Was Finalized (mm/dd/yyyy)
3. 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. [Fillable field]
[Page 6]
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
If you answered “Yes,” provide a detailed description of the dissolution. [Fillable field]
5. Have you ever previously placed a child in the care of another person with the intent to transfer permanent custody of the child? Yes No
If you answered “Yes,” provide a detailed description of the placement. [Fillable field]
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. [Fillable field]
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Pages 7-9,
Part 2. Information About Your Home Study Preparer and/or Adoption Service Provider
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[Page 7]
Part 2. Information About Your Home Study Preparer and/or Adoption Service Provider
1. Your home study: A. IS attached
to this Form I-600A. B. 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, U.S. Citizenship and Immigration Services (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 ZIP Code Province Postal Code Country
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)
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
[Page 8]
B. Point of Contact Within the Organization 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 ZIP Code Province Postal Code Country
D. Home Study Reviewer’s/Approver's Daytime Telephone Number
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. [Fillable field]
If you answered “No,” you must answer Item Number 5.
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. - E. below.
[] No, I have not yet identified a primary adoption service provider that will be responsible for my case.
NOTE: If you have not identified 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.
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
[Page 9]
B. Point of Contact Within the Organization Family Name (Last Name)
C. Primary Adoption Service Provider’s Daytime Telephone Number
D. Primary Adoption Service Provider’s Fax Number (if any)
E. Primary Adoption Service Provider’s Email Address (if any)
|
[Page 7]
Part 5. Information About Your Home Study Preparer and/or Primary Adoption Service Provider
1. Your home study: A. IS attached
to this Form I-600A. B. 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
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 ZIP Code Province Postal Code Country
[Page 8]
D. Home Study Preparer's Daytime Telephone Number
E. Home Study Preparer's Fax Number
F. Home Study Preparer's Email Address
Information About Your Home Study Reviewer and Approver
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
A. Name of Home Study Reviewer/Approver
B. Point of Contact Within the Organization 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 ZIP Code Province Postal Code Country
D. Home Study Reviewer’s/Approver's Daytime Telephone Number
E. Home Study Reviewer’s/Approver's Fax Number
F. Home Study Reviewer’s/Approver's Email Address
Information About Your Primary Adoption Service Provider
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. [Fillable field]
If you answered “No” to Item Number 4., you must answer Item Number 5.
[Page 9]
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.
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
[Page 9]
B. Point of Contact Within the Organization Family Name (Last Name)
C.
Primary Adoption Service Provider's Mailing Address
D. Primary Adoption Service Provider’s Daytime Telephone Number
E. Primary Adoption Service Provider’s Fax Number
F. Primary Adoption Service Provider’s Email Address
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
|
Page 9,
Part 3. Information About Your Intended Adoption(s) |
[Page 9]
Part 3. 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? Yes
No
3. If you answered "Yes"
to Item Number 2., provide the following information (if
available): A. Your Intended Departure
Date (mm/dd/yyyy) C. Place to Which You or Your Spouse (if married) Are Traveling
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? Yes No
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 9. Additional Information.
[Fillable Field]
6. Where do you wish to file
your Form I-600
orphan petition? (Complete one of the options below) 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? Yes No 8. If you answered "Yes," enter the number of children you plan to adopt.
|
[Page 9]
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? Yes
No [Page 10]
3. If you answered "Yes"
to Item Number 2., provide the following information (if
available): A. Your Intended Departure
Date (mm/dd/yyyy) C. Place to Which You or Your Spouse (if married) Are Traveling
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? Yes No
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.
[Fillable Field]
6. Where do you wish to file
your Form I-600
orphan petition? (Complete one of the options below) 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? Yes No 8. If you answered "Yes," enter the number of children you plan to adopt.
|
Page 10,
Part 4. Accommodations for Individuals With Disabilities and/or Impairments
|
[Page 10]
Part 4. 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 your disabilities and/or impairments? Yes No
2. If you answered “Yes,” select all applicable boxes below that indicate who has the disabilities and/or impairments.
Applicant Spouse Other Adult Household Member
3. 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): [Fillable Field]
B. Blind or have low vision and request the following accommodation: [Fillable Field] C. Another type of disability and/or impairment. (Describe the nature of the disability and/or impairment and the requested accommodation): [Fillable Field]
|
[Page 10]
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 your disabilities and/or impairments? Yes No
2. If you answered “Yes,” select all applicable boxes below that indicate who has the disabilities and/or impairments.
Applicant Spouse Adult Member of the Household
3. 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): [Fillable Field] [Page 11]
B. Blind or have low vision and request the following accommodation: [Fillable Field] C. Another type of disability and/or impairment. (Describe the nature of the disability and/or impairment and the requested accommodation): [Fillable Field]
|
Pages 10-11,
Part 5. Applicant’s Statement, Certification, Duty of Disclosure, and Signature
|
[Page 10]
Part 5. 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. The interpreter named in Part 7. read to me every question and instruction on this application and my answer to every question in [Fillable field], a language in which I am fluent, and I understood everything.
2. Applicant’s Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 8., [Fillable field], 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 as an adoptive parent.
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.
[Page 11]
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, 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.
Applicant’s Duty of Disclosure
I understand the ongoing duty to disclose information concerning my suitability and eligibility as an adoptive parent, 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
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.
|
[Page 11]
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. The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every question in [Fillable field], a language in which I am fluent, and I understood everything.
2. Applicant’s Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 11., [Fillable field], 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.
[Page 12]
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
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.
|
Pages 11-12,
Part 6. Your Spouse’s Statement, Certification, Duty of Disclosure, and Signature |
[Page 11]
Part 6. 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.)
A. I can read and understand English, and have read and understand every question and instruction on this application and my answer to every question.
B. The interpreter named in Part 7. read to me every question and instruction on this application and my answer to every question in [Fillable field], a language in which I am fluent, and I understood everything.
2. Spouse’s Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 8., [Fillable field], 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 as an adoptive parent.
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.
[Page 12]
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, 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.
Your Spouse's Duty of Disclosure
I understand the ongoing duty to disclose information concerning my suitability and eligibility as an adoptive parent, 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
|
[Page 12]
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.)
A. I can read and understand English, and have read and understand every question and instruction on this application and my answer to every question.
B. The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every question in [Fillable field], a language in which I am fluent, and I understood everything.
2. Spouse’s Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 11., [Fillable field], 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.
[Page 13]
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
|
Pages 12-13,
Part 7. Interpreter’s Contact Information, Certification, and Signature |
[Page 12]
Part 7. 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)
Interpreter’s Mailing
Address 3. Street Number and Name Apt. Ste. Flr. City or Town
Interpreter’s Contact
Information 4. Interpreter's Daytime Telephone Number 5. Interpreter’s
Mobile Telephone Number (if any)
[Page 13]
I certify, under penalty of perjury, that:
I am fluent in English and [Fillable field], which is the same language specified in Parts 5. and 6., 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 their 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.
Interpreter’s Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)
|
[Page 13]
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)
Interpreter’s Mailing
Address 3. Street Number and Name Apt. Ste. Flr. City or Town
Interpreter’s Contact
Information 4. Interpreter's Daytime Telephone Number 5. Interpreter’s
Mobile Telephone Number (if any)
I certify, under penalty of perjury under the laws of the United States, that:
I am fluent in English and [Fillable field], 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.
[Page 14]
Interpreter’s Signature 7. Interpreter's Signature Date of Signature (mm/dd/yyyy)
|
Pages 13-14,
Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant and Spouse |
[Page 13]
Part 8. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant and Spouse
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 Mailing Address
3. Street Number and
Name City or Town
Preparer’s Contact Information
4. Preparer’s
Daytime Telephone Number
[Page 14]
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 (if married) 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 (if married) in this case extends/does not extend beyond the preparation of this application.
Preparer’s
Certification By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant and/or the applicant’s spouse (if married). The applicant and the applicant’s spouse (if married) 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 on information that the applicant provided to me or authorized me to obtain or use.
Preparer’s Signature
8. Preparer's Signature
|
[Page 14]
Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, If Other Than the Applicant and Spouse
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 Mailing Address
3. Street Number and
Name City or Town
Preparer’s Contact Information
4. Preparer’s
Daytime Telephone Number
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.
[Page 15]
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.
Preparer’s Signature
8. Preparer's Signature
|
Page 15,
Part 9. Additional Information |
[Page 15]
Part 9. 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) [Auto-populated field] Given Name (First Name) [Auto-populated field] Middle Name [Auto-populated field]
2. A-Number (if any) [Auto-populated field]
3. A. Page Number B. Part Number C. Item Number D. [Fillable field]
4. A. Page Number B. Part Number C. Item Number D. [Fillable field]
5. A. Page Number B. Part Number C. Item Number D. [Fillable field]
6. A. Page Number B. Part Number C. Item Number D. [Fillable field]
|
[Page 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 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) [Auto-populated field] Given Name (First Name) [Auto-populated field] Middle Name [Auto-populated field]
2. A-Number (if any) [Auto-populated field]
3. A. Page Number B. Part Number C. Item Number D. [Fillable field]
4. A. Page Number B. Part Number C. Item Number D. [Fillable field]
5. A. Page Number B. Part Number C. Item Number D. [Fillable field]
6. A. Page Number B. Part Number C. Item Number D. [Fillable field]
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mulvihill, Timothy R |
| File Modified | 0000-00-00 |
| File Created | 2021-01-13 |