I600A-015-FRM-FeeRule-OPSReview-FR-10232023

Application for
Advance Processing of an Orphan Petition
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-600A
OMB No. 1615-0028
Expires 12/31/2021

For USCIS Use Only

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The applicant is:
Married

Action Block

Receipt/Fee Stamp

Unmarried

The applicant is approved to adopt an
orphan from (if specified):
(Name of non-Hague Convention Country)

Remarks

Approval Valid Until (mm/dd/yyyy):

Final Adjudicating Office:

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

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

Attorney State Bar Number
(if applicable)

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

► 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.

Part 1. Basis of Filing

You are a U.S citizen who plans to adopt or has adopted a child from a country that is not party to the Hague Adoption
Convention.
You previously filed a Form I-600A; AND your marital status changed while your Form I-600A application was pending.

Part 2. Information About You (Applicant)
1.

Family Name (Last Name)

2.

Other Names Used (if any)

Given Name (First Name)

Middle Name (if applicable)

Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete
this section, use the space provided in Part 10. Additional Information.
Family Name (Last Name)

Form I-600A Edition 12/21/19 E

Given Name (First Name)

Middle Name (if applicable)

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Part 2. Information About You (Applicant) (continued)
Your Contact Information
3.

4.

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

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Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

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.

6.

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

Apt. Ste. Flr. Number

City or Town

State

Address Abroad (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

7.

Daytime Telephone Number

9.

Email Address (if any)

Postal Code

ZIP Code

Country

8.

Mobile Telephone Number (if any)

Information About Your U.S. Citizenship
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

Form I-600A Edition 12/21/19 E

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Part 2. Information About You (Applicant) (continued)
15. How did you obtain your U.S. citizenship?

Birth

Parents

Naturalization

A. If you obtained your citizenship through your parents, have you obtained a Certificate of Citizenship in
your own name?

Yes

No

If you answered “Yes,” provide the following information about your Certificate of Citizenship:

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Your Name On the Certificate of Citizenship
Family Name (Last Name)

Given Name (First Name)

Alien Registration Number (A-Number) (if any)
►

Middle Name (if applicable)

Certificate of Citizenship Number

A-

Date of Issuance (mm/dd/yyyy)

Place of Issuance

B. If you obtained your citizenship through naturalization, provide the following information about your Certificate of
Naturalization:
Your Name On The Certificate of Naturalization
Family Name (Last Name)

Given Name (First Name)

Middle Name (if applicable)

Certificate of Naturalization Number

A-Number (if any)
► A-

Date of Naturalization (mm/dd/yyyy)

Place 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 10. Additional Information.
17. What is your marital status?

Married

Single

Separated

Divorced

Widowed

18. How many times have you been married (including your current marriage, if applicable)?
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
Family Name (Last Name)

Form I-600A Edition 12/21/19 E

Given Name (First Name)

Middle Name (if applicable)

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Part 2. Information About You (Applicant) (continued)
22. Other Names Your Current Spouse Has Used (if any)
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 10. Additional Information.
Given Name (First Name)

Family Name (Last Name)

Middle Name (if applicable)

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23. Information About Your Current Spouse

Spouse's Date of Birth (mm/dd/yyyy) Spouse's A-Number (if any)
►

Spouse's USCIS Online Account Number (if any)
►

A-

Spouse's City/Town/Village of Birth

Spouse's State or Province of Birth

Spouse's Country of Birth

Is your spouse a U.S. citizen?

If you answered “Yes,” how did your spouse obtain citizenship?

Birth

Naturalization

Yes

No

Yes

No

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)?

Your Spouse's Contact Information

25. Does your current spouse reside with you?

If you answered “No,” provide your current spouse's physical address in Item Number 26.
26. Your Current Spouse's Physical Address (if applicable)
Street Number and Name

Apt. Ste. Flr. Number

State

City or Town

Province

27. Your Spouse's Daytime Telephone Number

Postal Code

ZIP Code

Country

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.
Form I-600A Edition 12/21/19 E

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Part 2. Information About You (Applicant) (continued)
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 10. Additional Information.
Date of Birth
(mm/dd/yyyy)

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Name (First/Middle/Last)

Country of Birth

A-Number (if any)

Relationship to You

Information About Prior Filings or Adoptions

If you need extra space to complete Item Numbers 32. - 37., use the space provided in Part 10. 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 Petition/Application Filed:
Form I-600A
Result:

Form I-600

Approved

Denied

Form I-800A
Withdrawn

Form I-800

Form I-130 (for an adopted child)

Revoked

Other (please explain):
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.

Form I-600A Edition 12/21/19 E

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Part 2. Information About You (Applicant) (continued)
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.

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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

Yes

No

If you answered “Yes,” provide a detailed description of the placement.

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 a state/local process?
If you answered “Yes,” provide a detailed description of the custody transfer.

Duty of Disclosure

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 10. 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

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.)
Form I-600A Edition 12/21/19 E

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Part 2. Information About You (Applicant) (continued)
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

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No

Part 3. Information About Your Home Study Preparer and/or Adoption Service Provider
1.

Your home study:
A.
B.

IS attached to this Form I-600A.

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

Province

Postal Code

D. Home Study Preparer's Daytime Telephone Number

ZIP Code

Country

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.

Form I-600A Edition 12/21/19 E

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Part 3. Information About Your Home Study Preparer and/or Adoption Service Provider (continued)
3.

Information About Who Reviewed And Approved (or will review and approve) Your Home Study (if applicable)
A. Name of Home Study Reviewer/Approver

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B. Point of Contact Within the Organization (if applicable)
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

Province

Postal Code

D. Home Study Reviewer's/Approver's Daytime Telephone
Number

ZIP Code

Country

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.

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 Items 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

Form I-600A Edition 12/21/19 E

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Part 3. Information About Your Home Study Preparer and/or Adoption Service Provider (continued)
B. Point of Contact Within the Organization
Family Name (Last Name)

Given Name (First Name)

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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)

Part 4. 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?

3.

If you answered “Yes” to Item Number 2., provide the following information (if available):
A. Your Intended Departure Date
(mm/dd/yyyy)

Yes

No

Yes

No

B. Your Spouse's Intended Departure Date
(mm/dd/yyyy)

C. Place to Which You or Your Spouse (if married) Are Traveling
City or Town

Province

Country

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?

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
10. Additional Information.

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?

8.

If you answered “Yes,” enter the number of children you plan to adopt.

Form I-600A Edition 12/21/19 E

Yes

No

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Part 5. 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 disabilities and/or impairments?

2.

If you answered “Yes,” select all applicable boxes below that indicate who has the disabilities and/or impairments.

No

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Applicant
3.

Yes

Spouse

Other Adult Household Member

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.

B.

C.

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)):

Blind or have low vision and request the following accommodation:

Another type of disability and/or impairment. (Describe the nature of the disability and/or impairment and the requested
accommodation):

Part 6. 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.

2.

The interpreter named in Part 8. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am fluent, and I
understood everything.

Applicant's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 9.,

,

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.

Form I-600A Edition 12/21/19 E

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Part 6. Applicant's Statement, Certification, Duty of Disclosure, and Signature (continued)
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

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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

Date of Signature (mm/dd/yyyy)

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.

Part 7. 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.

2.

The interpreter named in Part 8. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am fluent, and I
understood everything.

Spouse's Statement Regarding the Preparer (if applicable)
At my request, the preparer named in Part 9.,
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.

Form I-600A Edition 12/21/19 E

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Part 7. Your Spouse's Statement, Certification, Duty of Disclosure, and Signature (continued)
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

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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

Date of Signature (mm/dd/yyyy)

Part 8. 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)

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 Edition 12/21/19 E

5.

Interpreter's Mobile Telephone Number (if any)

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Part 8. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Certification
I certify, under penalty of perjury, that:
,which is the same language specified in Parts 6. and 7.,

I am fluent in English and

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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)

Part 9. 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 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

ZIP Code

Country

Postal Code

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

Form I-600A Edition 12/21/19 E

5.

Preparer's Mobile Telephone Number (if any)

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Part 9. Contact Information, Declaration, and Signature of the Person Preparing this Application, If
Other Than the Applicant and Spouse (continued)
Preparer's Statement
7.

A.
B.

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.

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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

Form I-600A Edition 12/21/19 E

Date of Signature (mm/dd/yyyy)

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Part 10. 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.

DRAFT
NOT FOR
PRODUCTION
10/23/2023

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 (if applicable)

D.

6.

A. Page Number

D.

Form I-600A Edition 12/21/19 E

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