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

Supplement 1,
Listing of Adult Member of the Household
Department of Homeland Security
U.S. Citizenship and Immigration Services

USCIS
Form I-600A/I-600
Supplement 1
OMB No. 1615-0028
Expires 02/28/2026

► 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.

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

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Form I-600A/I-600 Supp 1 Edition 04/01/24

ZIP Code

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

Address Abroad (if any)
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

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Province

7.

Daytime Telephone Number

9.

Email Address (if any)

Country

Postal Code

8.

Mobile Telephone Number (if any)

Adult Member of the Household's Biographical Information
10.

Date of Birth (mm/dd/yyyy)

11.

City/Town/Village of Birth

State or Province of Birth

Country of Birth

12.

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

A-

13.

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.

Form I-600A/I-600 Supp 1 Edition 04/01/24

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Part 1. Information About an Adult Member of the Household (continued)
Has the adult member of the household EVER, whether in or outside the United States:
14.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

14.b. Received a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?

Yes

No

14.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

14.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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Part 2. Adult Member of the Household's 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.
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 Certification

I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
this supplement, I read and understand or, if interpreted by me in a language in which I am fluent by the interpreter listed in Part 6.,
understood, all of the responses and information contained in, and submitted with, this supplement, and that all of the responses and
the information are complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records
that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.

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
1.

Adult Member of the Household's Signature

Form I-600A/I-600 Supp 1 Edition 04/01/24

Date of Signature (mm/dd/yyyy)

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

Family Name (Last Name)

2.

Date of Birth (mm/dd/yyyy)

3.

City/Town/Village of Birth

Given Name (First Name)

Middle Name (if applicable)

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State or Province of Birth

Country of Birth

4.

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

Daytime Telephone Number

A-

6.

Mobile Telephone Number (if any)

8.

USCIS Online Account Number (if any)
►

5.

7.

Email Address (if any)

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

I certify, under penalty of perjury, that I provided or authorized all of the responses and information contained in and submitted with
my supplement, I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 5.,
understood, all of the responses and information contained in, and submitted with, my supplement, and that all of the responses and
the information are complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records
that USCIS may need to determine my eligibility for an immigration request and to other entities and persons where necessary for the
administration and enforcement of U.S. immigration law.
1.

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)

2.

Interpreter's Business or Organization Name

Form I-600A/I-600 Supp 1 Edition 04/01/24

Interpreter's Given Name (First Name)

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Part 5. Interpreter's Contact Information, Certification, and Signature (continued)
Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

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Interpreter's Certification and Signature

I certify, under penalty of perjury, that I am fluent in English and

, and I

have interpreted every question on this supplement and interpreted to the adult member of the household's and/or applicant's/
petitioner's answers to the questions in that language, and the adult member of the household and/or applicant/petitioner informed me
that they understood every instruction, question, and answer on this supplement.
6.

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
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this supplement for the applicant/petitioner and/or adult member of the household at
their request and with express consent and that all of the responses and information contained in and submitted with this supplement
are complete, true, and correct. The applicant/petitioner and/or adult member of the household reviewed the responses and information
and informed me that they understand the responses and information in or submitted with this supplement.
6.

Preparer's Signature

Form I-600A/I-600 Supp 1 Edition 04/01/24

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.
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.

Page Number

Part Number

Item Number

4.

Page Number

Part Number

Item Number

5.

Page Number

Part Number

Item Number

6.

Page Number

Part Number

Item Number

Form I-600A/I-600 Supp 1 Edition 04/01/24

Given Name (First Name)

Middle Name (if applicable)

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DHS Privacy Notice
AUTHORITIES: USCIS is collecting the information requested on this supplement, and the associated evidence, under the
Immigration and Nationality Act (INA) 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 primary purpose for
providing the requested information on 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. The Department of Homeland
Security (DHS) uses the information you provide to grant or deny the immigration benefit the applicant/petitioner is seeking.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including your
Social Security number (if applicable), and any requested evidence, may delay a final decision or result in USCIS denying the
underlying adoption-related application and/or petition.
ROUTINE USES: DHS may, where allowable under relevant confidentiality provisions, 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 Supp 1 Edition 04/01/24

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