Fillable Printable Form I-800A Supplement 1

Form I-800A Supplement 1

Form I-800A, Supplement 1, Listing

of Adult Member of the Household

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-800A, Supplement 1 (Rev. 03/10/17 N)

Part 1. Information About an Adult Member of the Household. (You must

complete Form I-800A, Supplement 1, for each adult member of the household

age 18 and older. However, if you are married, you do not need to complete one

for your spouse.)

Notice to the Adult Member of the Household: By signing Form I-800A, Supplement 1,

you agree that USCIS may disclose to the applicant or the applicant's adoption service

provider information that USCIS may obtain about you that is relevant to the adjudication

of the applicant's Form I-800A, even if the Privacy Act, 5 U.S.C. 552a, might otherwise

prevent disclosure of the information.

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 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; 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.

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

Remarks:

START HERE - Type or Print (Use black ink)

For USCIS Use Only

1. Provide the following information about the adult member of the household:

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

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?

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?

Other Names Used (including maiden name if appropriate)

Family Name (Last Name)

A # (if any) U.S. Social Security # (if any)

Given Name (First Name) Middle Name

Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)

C/O (in care of)

Mailing Address

City State or Province CountryZip/Postal Code

Apt. #

Yes

Yes No

Form I-800A, Supplement 1 (Rev. 03/10/17 N) Page 2

E-Mail Address

(if any)

I declare that I completed Form I-800A, Supplement 1, Part 1 and it is based on all information of which I have knowledge. I have

not knowingly withheld any material information that would affect the outcome of this application.

Adult Member of the Household's Signature

Pursuant to the Privacy Act, 5 U.S.C. 552a, I also authorize USCIS to disclose information about me which may appear in any system

of records maintained by the U.S. Department of Homeland Security, or which USCIS may obtain as a result of the collection of my

biometrics information, to the applicant(s) who have filed Form I-800A, or to the applicant's adoption service provider, in order to

assist USCIS in adjudicating Form I-800A.

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 the adult member of the household:

2. I understand the ongoing duty to disclose any change in circumstance, as described on Page 7 of the instructions to Form

I-800A. I agree to notify the applicant of any new information that I am required to disclose.

Other Names Used (including maiden name if appropriate)

Date (mm/dd/yyyy)

Your Signature (Applicant)

Applicant Family Name (Last Name) Applicant Middle NameApplicant Given Name (First Name)

Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)

USCIS Account # (if any)

U.S. Social Security # (if any) A # (if any)

Date (mm/dd/yyyy)

Daytime Phone Number

(with area code)

Part 2. Signature of You, the Prospective Adoptive Parent (Applicant) and Signature and Certification of the Adult Member

of the Household (Read the information on penalties on Page 10 of the instructions before completing this section.)