Pages 1-6,
Part 1. Information
About You (Applicant)
|
[Page 1]
Part 2. Information About You
(Applicant)
1. Family Name (Last
Name)
Given Name (First Name)
Middle Name (if
applicable)
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 10. Additional Information.
Family Name (Last Name)
Given
Name (First Name)
Middle Name (if applicable)
Your Contact Information
3. U.S. Mailing Address (if
any)
In Care Of Name (if any)
Street Number and
Name
Apt. Ste. Flr.
Number
City or Town
State
ZIP
Code
[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)
Street Number and Name
Apt.
Ste. Flr.
Number
City or Town
State
ZIP
Code
6. Address Abroad (if
any)
Street Number and Name
Apt. Ste. Flr.
Number
City
or Town
State
Province
Postal Code
Country
7. Daytime Telephone Number
8. Mobile Telephone Number
(if any)
9. Email Address (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
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:
Your Name On the Certificate of
Citizenship
Family Name (Last Name)
Given
Name (First Name)
Middle Name (if applicable)
Alien Registration Number
(A-Number) (if any)
Certificate of Citizenship Number
Date
of Issuance (mm/dd/yyyy)
Place of Issuance
[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
Family Name (Last Name)
Given Name (First Name)
Middle
Name (if applicable)
A-Number (if any)
Certificate
of Naturalization Number
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?
Single
Married
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)
Given
Name (First Name)
Middle Name (if applicable)
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.
Family Name (Last Name)
Given
Name (First Name)
Middle Name (if applicable)
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)
Spouse’s City/Town/Village of
Birth
Spouse’s State or Province of Birth
Spouse’s
Country of Birth
[Page 4]
Is your spouse a U.S. citizen?
Yes No
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)?
Your Spouse’s
Contact Information
25. Does your current spouse
reside with you?
Yes
No
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
City or Town
State
ZIP Code
Province
Postal
Code
Country
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.
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.
[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)
[Page 5]
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]
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 a state/local process? Yes No
If you answered “Yes,”
provide a detailed description of the custody transfer.
[Fillable field]
[Page 6]
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
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
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
|
[Page 1]
Part 2. Information About You
(Applicant)
1. Family Name (Last
Name)
Given Name (First Name)
Middle Name (if
applicable)
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.
[no change]
[Page 2]
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
ZIP
Code
[no change]
12. City/Town/Village of
Birth
State or Province of
Birth
Country of Birth
[Page 3]
13.a.
How did you obtain your U.S.
citizenship?
Birth
Parents
Naturalization
13.b.
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:
Your Name On the Certificate of
Citizenship
Family Name (Last Name)
Given
Name (First Name)
Middle Name (if applicable)
Alien Registration Number
(A-Number) (if any)
Certificate of Citizenship Number
Date
of Issuance (mm/dd/yyyy)
Place of Issuance
13.c.
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)
A-Number (if any)
Certificate
of Naturalization Number
Date of Naturalization
(mm/dd/yyyy)
Place of Naturalization
14.
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.
15.
What is your marital status?
Single
Married
Divorced
Widowed
Separated
16.
How many times have you been married (including your
current marriage, if applicable)?
NOTE: If you are not
currently married, skip to Item Number 28.
Information About Your Current
Marriage
17.
Date of Current Marriage (mm/dd/yyyy)
18.
Place Where Current Marriage Occurred
19.
Name of Your Current Spouse
Family Name (Last Name)
Given
Name (First Name)
Middle Name (if applicable)
[Page
4]
20.
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 9. Additional
Information.
Family Name (Last Name)
Given
Name (First Name)
Middle Name (if applicable)
21.
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)
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?
Yes/No
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:
22.
How many times has your current spouse been married
(including your current marriage, if applicable)?
Your Spouse’s
Contact Information
23.
Does your current spouse reside with you?
Yes
No
If you answered "No,"
provide your current spouse's physical address in Item Number
24.
24.
Your Current Spouse's Physical Address (if applicable)
Street
Number and Name
Apt. Ste. Flr.
Number
City or Town
State
ZIP Code
Province
Postal
Code
Country
25.
Your Spouse’s Daytime Telephone Number
26.
Your Spouse’s Mobile Telephone Number (if any)
27.
Your Spouse’s Email Address (if any)
[Page 5]
Additional Household Members
28.
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.
29.
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 30. - 35.,
use the space provided in Part 9.
Additional Information.
30.
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)
31.
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)
[Page 6]
32.
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]
33.
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]
34.
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]
35.
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]
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 36. and
37., 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.
Have you
EVER, whether in or outside the United States:
36.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
36.b.
Received a pardon, amnesty, rehabilitation decree, other
act of clemency, or similar action? Yes No
[Page 7]
36.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
36.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
Has your
spouse EVER, whether in or outside the United States:
37.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
37.b.
Received the beneficiary of a pardon, amnesty,
rehabilitation decree, other act of clemency, or similar action?
Yes No
37.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
37.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
|
Pages 7-9,
Part 2. Information
About Your Home Study Preparer and/or Adoption Service Provider
|
[Page 7]
Part 3. 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
B. Point of Contact Within
the Organization
Family Name (Last Name)
Given Name (First Name)
[Page 8]
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 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
[Page 9]
B. Point of Contact Within
the Organization
Family Name (Last Name)
Given
Name (First 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 3. Information About Your
Home Study Preparer and/or Adoption Service Provider
Your home
study:
1.a.
IS attached to this Form I-600A.
1.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
Information
About Who Prepared or Will Prepare Your Home Study
2.a.
Name of Home Study Preparer
2.b.
Point of Contact Within the Organization (if applicable)
Family Name (Last Name)
Given Name (First Name)
2.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]
2.d.
Home Study Preparer's Daytime Telephone Number
2.e.
Home Study Preparer's Fax Number (if any)
2.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.
Information
About Who Reviewed And Approved (or will review and
approve) Your Home Study (if applicable)
3.a.
Name of Home Study Reviewer/Approver
3.b.
Point of Contact Within the Organization
Family Name (Last Name)
Given Name (First Name)
3.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
3.d.
Home Study Reviewer’s/Approver's Daytime Telephone
Number
3.e.
Home Study Reviewer’s/Approver's Fax Number (if any)
3.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
Numbers 2.a. - 2.f.
or Item Numbers 3.a. - 3.f.
is serving as your primary adoption service provider.
[Fillable field]
If you answered “No,”
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 Numbers 6.a. -
6.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.
6.a.
Name of Primary Adoption Service Provider
6.b.
Point of Contact Within the Organization
Family Name (Last Name)
Given
Name (First Name)
6.c.
Primary Adoption Service Provider’s Daytime
Telephone Number
6.d.
Primary Adoption Service Provider’s Fax Number (if
any)
6.e.
Primary Adoption Service Provider’s Email Address
(if any)
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Pages 10-11,
Part 5. Applicant’s
Statement, Certification, Duty of Disclosure, and Signature
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[Page 10]
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. 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
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.
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[Page 10]
Part 5.
Applicant’s
Certification,
Duty of Disclosure, and Signature
[deleted]
Applicant’s
Certification
[deleted]
I
certify,
under penalty of perjury, that I provided or authorized all of the
responses
and information
contained
in
and submitted
with my
application, I read
and understand
or,
if interpreted to me in a language in which I am fluent by the
interpreter listed in Part
7.,
understood,
all of the responses
and information
contained in, and submitted with, my application, 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.
[no change]
1.
Applicant’s Signature
Date of Signature
(mm/dd/yyyy)
[deleted]
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Pages 11-12,
Part 6. Your
Spouse’s Statement, Certification, Duty of Disclosure, and
Signature
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[Page 11]
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. 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
Date of Signature (mm/dd/yyyy)
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[Page 10]
Part 6.
Your Spouse’s
Certification,
Duty of Disclosure, and Signature
[deleted]
Your
Spouse’s Certification
[deleted]
I
certify, under penalty of perjury, that I provided or authorized
all of the responses
and information
contained
in
and
submitted with my
application, I read
and understand
or,
if interpreted to me in a language in which I am fluent by the
interpreter listed in Part
7.,
understood, all
of the responses
and information
contained in, and submitted with, my application, 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.
[Page
11]
[no change]
1.
Your Spouse’s Signature
Date of Signature
(mm/dd/yyyy)
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