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Notice
The Privacy Act protects information
that U.S. Citizenship and Immigration Services (USCIS) may have
concerning your Form I-600A, Application for Advance Processing of
an Orphan Petition, or Form I-600, Petition to Classify Orphan as
an Immediate Relative. See 5 U.S.C. 552a. USCIS generally may
not disclose this information without your consent. If you want
USCIS to be able to disclose this information, you may give this
consent by signing Form I-600A/I-600, Supplement 2. You are not
required to submit Form I-600A/I-600, Supplement 2, to file Form
I-600A or Form I-600.
This supplement does not cover your
attorney or accredited representative. In order for USCIS to
share information with an individual who is your legal
representative, you must submit Form G-28, Notice of Entry of
Appearance as Attorney or Accredited Representative, or Form
G-28I, Notice of Entry of Appearance as Attorney In Matters
Outside the Geographical Confines of the United States.
Provide information below about
the individual or entity that you are authorizing USCIS to
disclose information to. This could include your home study
preparer, the agency that reviewed and approved your home study,
your primary adoption service provider, or any other individual or
entity (other than your attorney or accredited representative) to
whom USCIS may disclose information. For more information about
home study preparers and primary adoption service providers, see
the Instructions for Form I-600 and Form I-600A.
Pursuant to the Privacy Act, 5 USC
552a, and to assist USCIS in adjudicating Form I-600A and/or Form
I-600, I (we), the undersigned applicants/petitioners filing Form
I-600A and/or Form I-600, consent to the disclosure of any record
pertaining to me (us), which appears in any system of records
maintained by the U.S. Department of Homeland Security (DHS), or
which USCIS may obtain as a result of collecting my (our)
biometrics information, to the following individual or entity:
1. Name of Individual or
Entity
2. Point of Contact (contact person within the
entity) (if any)
3. Street Number and
Name
Apt. Ste. Flr. Number
City or Town
State
ZIP
Code
Province
Postal Code
Country
4. Daytime Telephone Number
(with area/country code)
5. Mobile Telephone Number
(if any)
6. Email Address (if any)
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I (We) understand that, by signing
this supplement, I am (we are) authorizing USCIS to provide the
individual or entity named above with copies of notices sent to me
(us) about this case and discuss my (our) case with the individual
or entity named in this supplement.
I (We) also understand that an
adoption service provider, home study preparer, and home study
reviewer can only provide adoption services and cannot act as my
(our) representative before USCIS with respect to my (our) case
unless the adoption service provider/home study preparer is
authorized to do so under 8 CFR 292. I (We) also understand that
the adoption service provider, home study preparer, and home study
reviewer cannot provide any other legal services unless the
adoption service provider/home study preparer is authorized to do
so under the law governing the provision of legal services in the
country or state in which the legal service is provided.
7. Your Printed Name
8. Your Signature
Date
of Signature (mm/dd/yyyy)
9. Your Spouse’s
Printed Name (if you are married)
10. Your Spouse’s
Signature
Date (mm/dd/yyyy)
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9. Your Spouse’s
Printed Name (if you are married)
10. Your Spouse’s
Signature
Date of
Signature (mm/dd/yyyy)
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