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

Supplement 1,
Listing of Adult Member of the Household

USCIS
Form I-600A/I-600
Supplement 1

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

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 separate Supplement 1 for
yourself or your spouse (if married).

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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 Used by the Adult Member of the Household (if any)

Given Name (First Name)

Middle Name (if applicable)

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 (if applicable)

Adult Member of the Household's Contact Information
3.

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

4.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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

Yes

No

If you answered "No," provide the U.S. physical address in Item Number 5. or an address abroad in Item Number 6., as
appropriate.
5.

6.

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

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

Address Abroad (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

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

Postal Code

Country

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Part 1. Information About an Adult Member of the Household (continued)
7.

Daytime Telephone Number

9.

Email Address (if any)

8.

Mobile Telephone Number (if any)

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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) (if any)
►

A-

13. Country of Birth

15. USCIS Online Account Number (if any)
►

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 statement should include the following:
If signed outside the United States: “I declare (or certify, verify, or state) under penalty of perjury under the laws of the United
States of America that this statement is true and correct.”
If signed within the United States (including territories, possessions, and commonwealths): “I declare (or certify, verify, or state)
under penalty of perjury that this statement is true and correct.”
The written statement must also show the date of each incident; place the incident occurred (city/town, state/province, country); name
of the police department or other law enforcement administration or other entity involved; date of incarceration and name of facility, if
applicable; and include your (the applicant's/petitioner's) name and A-Number (if any) 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
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 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

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

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Part 2. Adult Member of the Household's Statement, Certification, Duty of Disclosure, and Signature
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, if
applicable, 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.

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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/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 or petitioner as an adoptive
parent.
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, 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.

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.

Adult Member of the Household's Signature
3.

Adult Member of the Household's Signature

Date of Signature (mm/dd/yyyy)

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

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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 (if any)
►

8.

A-

Given Name (First Name)

Middle Name (if applicable)

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3.

City/Town/Village of Birth

Mobile Telephone Number (if any)

5.

7.

Country of Birth

Daytime Telephone Number

9.

Email Address (if any)

10. USCIS Online Account Number (if any)
►

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

NOTE: If you or any adult member of the household knowingly and willfully falsify or conceal a material fact or submit a false
document with your Form I-600A/I-600, 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 Edition 12/21/19

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

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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 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, 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 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 Edition 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, that:

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I am fluent in English and

, which is the same language specified in Parts

2. and 4., Item B. in Item Number 1., and I have read to this adult member of the household and/or 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 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 you, the applicant/petitioner or adult member of the household 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 Edition 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.

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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 applicant/petitioner and with the adult member of the household's and/or 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
applicant/petitioner in this case
extends
does not extend beyond the preparation of this supplement.

Preparer's Certification

By my signature, I certify, under penalty of perjury, that I prepared this supplement at the request of the applicant/petitioner and/or
adult member of the household. The applicant/petitioner and adult member of the household 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 applicant/petitioner and/or
adult member of the household provided to me or authorized me to obtain or use.

Preparer's Signature
8.

Preparer's Signature

Form I-600A/I-600 Supplement 1 Edition 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 (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.

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1.

Family Name (Last Name)

2.

A-Number (if any) ► A-

3.

A. Page Number

D.

4.

A. Page Number

D.

5.

A. Page Number

Given Name (First Name)

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

Middle Name

D.

6.

A. Page Number

D.

Form I-600A/I-600 Supplement 1 Edition 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.

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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.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any
requested evidence, may delay a final decision or result in 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 and DHS/USCIS-005 - Inter-Country Adoptions Security] 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 USC 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 USC 552a, might otherwise prevent disclosure of the
information to the prospective adoptive parents.

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

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