Signed this day of , , at .
Subscribed and sworn to (or affirmed) before me this day of , ,
at . My commission expires on (mm-dd-yyyy) .
I, , certify that I am the adoptive parent/prospective
adoptive parent of a child, , on whose behalf I have filed or will file
an I-600 (Petition to classify orphan as immediate relative) according said child status as an orphan as defined by
Section 101(b)(1)(F), or an I-800 (Petition to classify convention adoptee as immediate relative) according said child
status as a convention adoptee as defined by Section 101(b)(1)(G).
I have read the statement above and I am aware of the vaccination requirement set forth in Section 212(a)(1)(A)(ii) of
the Immigration and Nationality Act. In accordance with Section 212(a)(1)(A)(ii), I will ensure that my foreign adopted
child receives the required and medically appropriate vaccinations within 30 days after his or her admission into the
U.S., or at the earliest time that is medically appropriate.
provided that the adoptive parent or prospective adoptive parent, prior to the child's admission, executes an affidavit
stating that the parent is aware of the provisions of subparagraph (A)(ii) and will ensure that, within 30 days of the
child's admission, or at the earliest time that is medically appropriate, the child will receive the vaccinations identified in
AFFIDAVIT CONCERNING EXEMPTION FROM IMMIGRANT
VACCINATION REQUIREMENTS FOR A FOREIGN ADOPTED CHILD
Statement for Parent(s): Section 212(a)(1)(A)(ii) of the Immigration and Nationality Act requires that any person who
seeks admission as an immigrant, or adjustment of status to the status of an alien lawfully admitted for permanent
residence, shall present documentation of having received vaccination against vaccine-preventable diseases,
specifically: mumps, measles, rubella, polio, tetanus and diphtheria toxoids, pertussis, influenza type B, hepatitis B,
varicella and pneumoccocal. This section exempts from the immunization requirement a child who:
(Signature of Parent)
(i) is 10 years of age or younger;
(ii) is described in Sections F or G of sections 101(b)(1), and
(iii) is seeking an immigrant visa as an immediate relative under section 201(b),
(Signature of Notary Public or Officer Administering Oath)
U.S Department of State
Affidavit by Adoptive Parent or Prospective Adoptive Parent
Confidentiality Statement - INA Section 222(f) provides that visa issuance and refusal records shall be considered
confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration,
nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which
certifies that the information contained in such records is needed in a case pending before the court.