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Fillable Printable Form I-800A

Fillable Printable Form I-800A

Form I-800A

Form I-800A

Form I-800A, Application for Determination of Suitability
to Adopt a Child from a Convention Country
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-800A (Rev. 03/10/17) N
Action Block
To Be Completed By
3. I am a habitual resident of the United States as:
START HERE - Type or Print (Use black ink)
Returned
Date
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
For USCIS Use Only
ATTY State License #
Attorney or Representative, if any.
Fill in box if G-28 is attached to
represent the applicant.
This application was filed by:
A Married Applicant
An Unmarried Applicant
This application is approved for a
Convention adoptee from:
(Name of Convention Country)
1. Provide the following information about yourself:
2. I intend to adopt a child habitually residing in the following Convention country:
Warning: If you are seeking to adopt a child who is habitually residing in a country
other than a Convention country, STOP. You cannot file this application. See Pages
1 to 2 of the Form I-800A instructions for additional filing information.
Period of approval valid until:
(Date)
State or Province
Other Names Used (including maiden name if appropriate)
Family Name (Last Name)
USCIS Account #
Home Address - Street Number and Name
U.S. Social Security # (if any)
CityState or Province
Zip/Postal CodeCountry
Apt. #
Mailing Address(if different from home address)
City
Zip/Postal CodeCountry
Apt. #
C/O (in care of)
Place of Birth (City/Town, State/Province, Country)
Given Name (First Name)Middle Name
Date of Birth (mm/dd/yyyy)
A person who will establish a domicile in the United States on or before the date
of the child's admission to the United States for permanent residence as a
Convention adoptee.
A person domiciled outside the United States who will bring the child to the
United States after adoption and before the child's 18th birthday for naturalization
as a U.S. citizen.
Part 1. Information About You (Person filing this application)
A person who is domiciled in the United States, even if temporarily living outside
the United States.
A person who is domiciled in the United States.
Form I-800A (Rev. 03/10/17) N Page 2
b. If married, provide the following information:
5. If you derived or acquired citizenship through your parent(s), have you obtained your own certificate of
citizenship?
If "Yes," provide the following information:
6. If you became a citizen by naturalization, give the following information:
7. Have you, or any person through whom you claimed citizenship, ever lost U.S. citizenship?
If "Yes," attach a detailed explanation including date, place, and circumstances on a separate
sheet of paper.
4. I am:
8. Provide the following information about your current marital status.
a. I am:
A citizen of the United States. I obtained my U.S. citizenship through:
Single, never married.
Married, with all previous marriages terminated. (If you check this box, you must complete 8,b, and c.)
Married, with no previous marriages. (If you check this box, you must complete 8,b.)
Single, with all previous marriages terminated. (If you check this box, you must complete 8,c.)
Not a citizen of the United States. STOP. You may not file this application (see Pages 1 to 2 of instructions for eligibility to
file).
Birth in the United StatesParent(s)Naturalization
YesNo
Name Under Which Certificate of Citizenship Was Issued
Place of
Issuance
A #
(if known)
Certificate of
Citizenship Number
Date of Issuance
(mm/dd/yyyy)
Name Under Which Certificate of Naturalization Was Issued
Place of
Naturalization
A #
(if known)
Naturalization
Certificate Number
Date of Naturalization
(mm/dd/yyyy)
YesNo
Part 1. Information About You (Continued)
Place of Current Marriage
(City/Town, State/Province, Country)
Date of Current Marriage
(mm/dd/yyyy)
Form I-800A (Rev. 03/10/17) N Page 3
Each of the above questions must be answered. See "Duty of Disclosure" on Page 7 of the instructions to Form I-800A
concerning your ongoing duty to disclose information in answer to these questions. If the answer is "Yes" to any of the
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 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 would like considered in light of this history
on a separate sheet of paper.
a. Date Marriage Ended
(mm/dd/yyyy)
How Marriage
Ended
2. Provide the following information on each terminated marriage (if applicable):
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?
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?
10. Have you ever, whether in or outside the United States:
d. 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?
b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar
action?
9. My contact information is (all phone numbers must include area code and country code, if applicable):
c. Information on all previous marriages, if applicable. Begin with the most recent termination.
NOTE: If you need more space to complete, use a separate sheet of paper. Write your name and USCIS Account Number, if
known, at the top of each sheet of paper and indicate the part and number of the item to which the answer refers.
1. Number of Previous Marriages
(Do not count current marriage)
Name of
Prior Spouse
DivorceDeathOther
b. Date Marriage Ended
(mm/dd/yyyy)
How Marriage
Ended
Name of
Prior Spouse
DivorceDeathOther
E-Mail Address
(if any)
Daytime Phone #
(with area/country code)
Home Phone #
(if different from daytime #)
YesNo
YesNo
YesNo
YesNo
Part 1. Information About You (Continued)
Form I-800A (Rev. 03/10/17) N Page 4
Name of
Prior Spouse
1. If you are married, provide the following information about your spouse:
3. Prior to your current marriage, has your spouse been previously married?
If "No," provide the following information. NOTE: If you are still legally married but separated from your spouse, you cannot
file this application unless your spouse will join in the submission of Form I-800A, subsequent Form I-800, Petition to Classify
Convention Adoptee as an Immediate Relative, and the adoption of the Convention child.
2. Does your spouse reside with you?
a. Number of Previous Marriages
(Do not count current marriage)
b. Provide the following information on each terminated marriage (if applicable):
If "Yes," provide the following information. Begin with the most recent termination.
Spouse's Contact Information
Part 2. Information About Your Spouse
Middle NameFamily Name (Last Name)Given Name (First Name)
USCIS Account # (if any)U.S. Social Security # (if any)A # (if any)
Other Names Used (including maiden name if appropriate)
Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)
YesNo
YesNo
Spouse's Mailing Address(if different from home address)
Home Address - Street Number and Name
CityState or ProvinceCountryZip/Postal Code
Apt. #
C/O (in care of)
City
State or ProvinceCountryZip/Postal Code
Apt. #
E-Mail Address
(if any)
Daytime Phone #
(with area/country code)
1. Date Marriage Ended
(mm/dd/yyyy)
How Marriage
Ended
DivorceDeathOther
Form I-800A (Rev. 03/10/17) N Page 5
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?
NOTE: If you need more space to complete, use a separate sheet of paper. Write your name and USCIS Account Number, if
known, at the top of each sheet of paper and indicate the part and number of the item to which the answer refers.
4. Your spouse:
5. If your spouse derived citizenship through his or her parent(s), has he or she obtained his or her own
certificate of citizenship?
If "Yes," provide the following information:
6. If your spouse became a citizen by naturalization, give the following information:
7. Has your spouse, or any person through whom he or she claimed citizenship, ever lost U.S. citizenship?
If "Yes," attach a detailed explanation on a separate sheet of paper.
8. Has your spouse ever, whether in or outside the United States:
2. Date Marriage Ended
(mm/dd/yyyy)
How Marriage
Ended
Name of
Prior Spouse
DivorceDeathOther
Is a citizen of the United States through:
Is a non-citizen national of the United States.
Is an alien who has been lawfully admitted for permanent residence.
Is an alien who has not been lawfully admitted for permanent residence. (Provide a full explanation on a separate sheet of
paper. Copies of any relevant documents relating to any other immigration status must be attached to Form I-800A. If your
spouse is an alien who does not live in the United States, provide a complete explanation.)
Birth in the United StatesParent(s)Naturalization
YesNo
YesNo
YesNo
Place of
Issuance
Name Under Which Certificate of Citizenship Was Issued
A #
(if known)
Certificate of
Citizenship Number
Date of Issuance
(mm/dd/yyyy)
Place of
Naturalization
Name Under Which Certificate of Naturalization Was Issued
A #
(if known)
Naturalization
Certificate Number
Date of Naturalization
(mm/dd/yyyy)
Part 2. Information About Your Spouse (Continued)
Form I-800A (Rev. 03/10/17) N Page 6
Street Number and Name
d. 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?
b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar
action?
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?
Each of the above questions must be answered. See "Duty of Disclosure" on Page 7 of the instructions to Form I-800A
concerning your ongoing duty to disclose information in answer to these questions. If the answer is "Yes" to any of the 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 your spouse 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 would like considered in light
of this history on a separate sheet of paper.
1. The home study:
2.Name and Address of Adoption Service Provider. Provide the name and address of either (Check one):
a.
b.
YesNo
YesNo
YesNo
Part 2. Information About Your Spouse (Continued)
Part 3. General Information
Is attached to this application.
Is not attached to this application because of State requirements necessitating review and documentation. The appropriate
State authority has indicated that it will submit the home study directly to USCIS. (Do not submit your Form I-800A to
USCIS until the State authority is ready to send the home study to USCIS.)
Name of Adoption Service Provider
CityState or Province
Country
Zip/Postal Code
Suite #
Point of Contact (contact person within the organization)
Daytime Phone # (with area/country code)
The primary adoption service provider who is responsible in your case, if you have already identified a primary adoption
service provider. (A primary adoption service provider is an accredited or temporarily accredited agency or approved
person who is responsible under 22 CFR Part 96.14 for the six adoption services defined in 22 CFR Part 96.2, and for
supervising and being responsible for supervised providers where used in a Convention adoption case.)
The adoption service provider that is responsible for your home study (either the accredited agency or temporarily accredited
agency, as defined in 22 CFR 96.2, that prepared and approved your home study or reviewed and approved your home study
after it was prepared by another authorized home study preparer, or the public domestic authority, as defined in 22 CFR
96.2, that both prepared and approved your home study); or
Form I-800A (Rev. 03/10/17) N Page 7
3. Provide a written description of the preadoption requirements, if any, of the State of the child's proposed residence when it is
known that the child will be adopted in the United States, including a citation to the relevant State statutes and regulations.
Describe the steps that have already been taken or that are planned to comply with these requirements. Any preadoption
requirements which cannot be met at the time Form I-800A is filed because of the operation of State law must be noted and
explained.
4. You plan to (Check one):
5. Do you plan to concurrently adopt more than one child from the same
Convention country? (Home study must contain a specific recommendation
for the number of children you plan to adopt.)
NOTE: If you need more space to complete, use a separate sheet of paper. Write your name and USCIS Account Number, if
known, at the top of each sheet of paper and indicate the part and number of the item to which the answer refers.
6. Have you ever previously filed Form I-600A, Application for Advance Processing of Orphan Petition,
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?
If "Yes," provide the following:
a. Type of Application/Petition Filed
b. Result - Check the box that best describes the action taken by USCIS and/or U.S. Department of State on your application and/
or petition.
NOTE: If you need more space to complete, use a separate sheet of paper. Write your name and USCIS Account Number, if known,
at the top of each sheet of paper and indicate the part and number of the item to which the answer refers.
Part 3. General Information (Continued)
Complete the proposed adoption in the Convention country.
a.
Obtain legal custody of the child in the Convention country and adopt the child in the United States. (If you selected Box 4,
b, make sure that you have properly completed Item 3 above.)
b.
YesNo
If "Yes," how many?
YesNo
Approved
- Approval Date (mm/dd/yyyy):
- Denial Date (mm/dd/yyyy):
Denied
Other
- Explain:
NOTE: A copy of the written denial notice must accompany this application.
Form I-800A (Rev. 03/10/17) N Page 8
Part 3. General Information (Continued)
7. Other than a spouse, is there any person 18 years of age or older residing with you?
If "Yes," you must complete Form I-800A Supplement 1, Listing of Adult Member of
the Household, for each person.
If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible
for the benefit sought and this application will be denied.
8. List all your children under 18 years of age. Also include any child under 18 years of age residing in your household even if you
are not the parent of such child.
2. I understand the ongoing duty to disclose information concerning my suitability as an adoptive parent, as described on Page 7
of the instructions to Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.
Your Signature
I certify, under penalty of perjury under the laws of the United States, that:
1. Each answer I have given to each question on Form I-800A and attached supplement(s) is true and correct to the best of my
knowledge, information, and belief; and
Your certification:
1. Each answer I have given to each question on Form I-800A and attached supplement(s) is true and correct to the best of my
knowledge, information, and belief; and
I certify, under penalty of perjury under the laws of the United States, that:
Certification of your spouse (if you are married):
2. I understand the ongoing duty to disclose information concerning my suitability as an adoptive parent, as described on Page 7
of the instructions to Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.
YesNo
Name
(First/Middle/Last)
Date of Birth
(mm/dd/yyyy)
Country
of Birth
A #
(if applicable)
Relationship to You
(if any)
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Signature of Spouse
Part 4. Certification and Signature of You, the Prospective Adoptive Parent(s)(Read the information on penalties in the
instructions before completing this section.)
Don’t forget to sign!
Don’t forget to sign!
Form I-800A (Rev. 03/10/17) N Page 9
E-Mail Address
(if any)
I declare that I prepared this application at the request of the above person(s), and it is based on all information provided to me by the
person(s). I have not knowingly withheld any material information that would affect the outcome of this application.
Attorney or Representative Only:
In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
ALSO: If you had assistance in filling out this application, the person preparing the form must complete Part 5. Only an individual
or organization provided for in 8 CFR Part 292 may represent you before USCIS and provide legal services in relation to this
immigration proceeding.
NOTICE: If you want to give consent for USCIS to disclose information about your case to your adoption service provider, you
should complete Form I-800A, Supplement 2, Consent to Disclose Information. You are not required to give this consent in order to
file Form I-800A.
YesNo
Preparer's Address
Date(mm/dd/yyyy)
Preparer's Signature
Preparer's Printed NamePreparer's Firm Name (if applicable)
Daytime Phone Number
(with area code)
Fax Number
(with area code)
Part 4. Certification and Signature of You, the Prospective Adoptive Parent(s) (Continued)
Part 5. Signature of Person Preparing Form if Other Than Above (Sign below)
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