Fillable Printable Form I-600A Supplement 1

Form I-600A Supplement 1

Form I-600A/I-600 Supplement 1 12/23/16 N Page 1 of 7

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 12/31/2018

Part 1. Information About an Adult Member of the Household

You must complete Form I-600A/Form I-600, Supplement 1, for each adult member of your household 18 years of age or older.

Note you do not need to complete one for yourself or your spouse (if married).

Provide the following information about the Adult Member of the Household:

U.S. Mailing Address (if any)

Family Name (Last Name)

Middle Name (if applicable)Given Name (First Name)Family Name (Last Name)

Given Name (First Name)Middle Name (if applicable)

Other Names You Have Used (including maiden name, nicknames, and aliases, if any)

City or TownStateZIP Code

Street Number and NameApt.Flr.NumberSte.

In Care Of Name

Number

U.S. Physical Address (if any)

Is your current U.S. mailing address the same as your U.S. physical address?

Street Number and Name

City or TownStateZIP Code

Apt.Flr.Ste.

If you answered "No" to Item Number 4., provide your U.S. physical address in Item Number 5. or your address abroad in Item

Number 6., as appropriate.

NoYes

Number

Address Abroad (if any)

Street Number and Name

City or TownState

Apt.Flr.Ste.

Postal CodeProvinceCountry

Date of Birth (mm/dd/yyyy)City/Town/Village of Birth 8.

Form I-600A/I-600 Supplement 1 12/23/16 N Page 2 of 7

You 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, signed by the adult member of the household 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; and date of incarceration and name of facility, if applicable. 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 on a separate sheet of paper; type or print your 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.

►

A-

Alien Registration Number (A-Number) (if any)11.

State or Province of Birth9.Country of Birth10.

Duty of Disclosure

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?

At any time been the subject of any investigation by any child welfare agency, court, or other official

authority in any State or foreign country concerning the abuse or neglect of any child, other than an

investigation that has been completed and formally closed based on a finding that the allegation of abuse

or neglect was unfounded or unsubstantiated?

Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?B.

Has the adult member of the household EVER, whether in or outside the United States:12.

A.Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any law

or ordinance, excluding traffic violations, but including driving or operating a vehicle while intoxicated

or while impaired by or under the influence of alcohol or other intoxicant, even if the record of the

arrest, conviction, or other adverse criminal history was expunged, sealed, pardoned, or the subject of

any other amelioration?

YesNo

Part 2. Information About You (Applicant or Petitioner Filing Form I-600A/I-600)

1. Family Name (Last Name)Given Name (First Name)Middle Name (if applicable)

►

A-

Alien Registration Number (A-Number) (if any)6.

2.Date of Birth (mm/dd/yyyy)City/Town/Village of Birth 3.

State or Province of Birth4.Country of Birth5.

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

Form I-600A/I-600 Supplement 1 12/23/16 N Page 3 of 7

Part 3. Adult Member of the Household's Statement, Contact Information, Certification, and Signature

Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2.

1.A.

1.B.

I can read and understand English, and have read and understand every question and instruction on this supplement, as well as

my answer to every question.

The interpreter named in Part 6. has read to me every question and instruction on this supplement, as well as my answer

I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided

complete, true, and correct responses.

to every question, in, a language in which I am fluent.

I have requested the services of and consented to

is not an attorney or accredited representative, preparing this supplement for me.

2.,

who is

Adult Member of the Household's Certification

Adult Member of the Household's Signature

Adult Member of the Household'sSignatureDate of Signature

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 the suitability and eligibility of the applicant or petitioner as an adoptive

parent.

I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records to

other entities and persons where necessary for the administration of U.S. immigration laws.

(mm/dd/yyyy)

Adult Member of the Household's Statement

Part 4. Adult Member of the Household's Duty of Disclosure

Certification: 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, and/or home study preparer and USCIS of

any new information that I am required to disclose.

Adult Member of the Household's SignatureDate of Signature

(mm/dd/yyyy)

AdultMember of the Household's Daytime Telephone NumberAdultMemberof the Household's Mobile TelephoneNumber (if any)

Adult Member of the Household's Email Address (if any)

3.4.

Adult Member of the Household's Contact Information

I certify, under penalty of perjury, that the information in my supplement and any document submitted with my supplement is

complete, true, and correct.

Form I-600A/I-600 Supplement 1 12/23/16 N Page 4 of 7

Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2.

1.A.

1.B.

I can read and understand English, and have read and understand every question and instruction on this supplement, as well as

my answer to every question.

to every question, in

The interpreter named in Part 6. has read to me every question and instruction on this supplement, as well as my answer

, a language in which I am fluent.

I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided

complete, true, and correct responses.

I have requested the services of and consented to

whois not an attorney or accredited representative, preparing this supplement for me.

Part 5. Applicant's or Petitioner's Statement, Contact Information, Certification, and Signature

Applicant's or Petitioner's Statement

Applicant's or Petitioner's Certification

Applicant's or Petitioner's Signature

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.

Applicant's or Petitioner'sSignatureDate of Signature

I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records; to

other entities and persons where necessary for the administration of U.S. immigration laws.

(mm/dd/yyyy)

Interpreter's Given Name (First Name)Interpreter's Family Name (Last Name)1.

Interpreter's Full Name

Interpreter's Business or Organization Name (if any)2.

Part 6. Interpreter's Name, Contact Information, Certification, and Signature

If the adult member of the household and/or applicant or petitioner used an interpreter, the interpreter must provide the following

information:

Applicant's or Petitioner's Daytime Telephone NumberApplicant's or Petitioner's Mobile Telephone Number (if any)

Applicant's or Petitioner's Email Address (if any)

3.4.

Applicant's or Petitioner's Contact Information

I certify, under penalty of perjury, that the information in my supplement and any document submitted with my supplement is

complete, true, and correct.

Form I-600A/I-600 Supplement 1 12/23/16 N Page 5 of 7

Interpreter's Mailing Address

City or TownStateZIP Code

Postal CodeProvinceCountry

Street Number and NameApt.Flr.NumberSte.

Part 6. Interpreter's Name, Contact Information, Certification, and Signature (continued)

Interpreter's Contact Information

Interpreter's Daytime Telephone NumberInterpreter's Email Address (if any)4.5.

Interpreter's Certification

I certify that:

I am fluent in English and .

I have read to this adult member of the household and/or applicant or petitioner every question and instruction on this supplement, as

well as the answer to every question in the language in which he and/or she is fluent; and

The adult member of the household and/or applicant or petitioner has informed me that he and/or she understands every instruction

and question on the supplement, as well as his and/or her answers to every question, and the adult member of the household and/or

applicant or petitioner verified the accuracy of every answer.

Date of SignatureInterpreter's Signature

(mm/dd/yyyy)

Interpreter's Signature

Preparer's Full Name

Preparer's Given Name (First Name)Preparer's Family Name (Last Name)1.

Preparer's Business or Organization Name (if any)2.

Part 7.Name, Contact Information, Statement, Certification, and Signature of the Person Preparing

this Supplement, If Other Than the Adult Member of the Household, and/or Applicant or Petitioner

If the adult member of the household and/or applicant or petitioner used a preparer to complete this supplement, the preparer must

provide the following information:

Form I-600A/I-600 Supplement 1 12/23/16 N Page 6 of 7

Preparer's Mailing Address

Street Number and NameApt.Flr.NumberSte.

City or TownStateZIP Code

Postal CodeProvinceCountry

Part 7.Name, Contact Information, Statement, Certification, and Signature of the Person Preparing

this Supplement, If Other Than the Adult Member of the Household, and/or Applicant or Petitioner

(continued)

Preparer's Contact Information

Preparer's Daytime Telephone Number Preparer's Fax Number (if any)

Preparer's Email Address (if any)

Preparer's Statement

I am not an attorney or accredited representative but have prepared this supplement on behalf of the adult member of the

household and/or applicant or petitioner and with the adult member of the household's and/or applicant's or petitioner's

consent.

I am an attorney or accredited representative and my representation of the adult member of the household and/or applicant

extendsor petitioner in this case does not extend beyond the preparation of this supplement.

7.A.

7.B.

Preparer's Signature

Date of Signature

(mm/dd/yyyy)

Preparer's Certification

Preparer's Signature

By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this supplement on behalf of, at the request of,

and with the express consent of the adult member of the household and/or applicant or petitioner. I completed this supplement based

only on responses the adult member of the household and/or applicant or petitioner provided to me. After completing the supplement,

I reviewed it and all of the adult member of the household's and/or applicant's or petitioner's responses with the adult member of the

household and/or applicant or petitioner, who agreed with every answer on the supplement. If the adult member of the household and/

or applicant or petitioner supplied additional information concerning a question on the supplement, I recorded it on the supplement.

NOTE: If you are an attorney or accredited representative whose representation extends beyond the preparation of this

supplement, you must submit a completed 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, with this supplement.

Form I-600A/I-600 Supplement 1 12/23/16 N Page 7 of 7

AUTHORITY: The information requested on this application, petition, and/or supplement, and the associated evidence, is collected

under Section 101(b)(1)(F) of the Immigration and Nationality Act (INA) [8 USC 1101], 8 CFR 204.3, and 8 CFR 204.311.

USCIS Privacy Act Statement

PURPOSE: The purpose of Supplement 1 is to collect information on any adult members of the household.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested

evidence, may delay a final decision or result in denial of your application or petition.

ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local, and foreign government

agencies and authorized organizations following approved routine uses described in the associated published system of records notices

[DHS/USCIS-005 - Inter-Country Adoptions Security and DHS/USCIS-001 - Alien File, Index, and National File Tracking System of

Records, which can be found at www.dhs.gov/privacy

]. The information may also be shared, as appropriate, for law enforcement

purposes or in the interest of national security.

This Supplement must be completed for any individual, other than you and your spouse (if married), who has the same principal

residence as you and is 18 years of age or older on or before the date that Form I-600A or Form I-600 is filed. Residence is defined as

the place of general abode or a person's principal, actual dwelling place in fact, without regard to intent. USCIS reserves the right to

request information on any household member who has not yet reached his or her 18th birthday before the date when Form I-600A or

Form I-600 is filed, or who does not actually live at the same residence, but whose presence in the residence is relevant to the issue of

your and your spouse's suitability to adopt.