Fillable Form I-800A, Application for Determination of Suitability: to (ILW.COM)

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Form I-800A, Application for Determination of Suitability: to (ILW.COM)

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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 (02/25/08) N
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.
Action Block
To Be Completed By
3. I am a habitual resident of the United States as:
START HERE - Please 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)
City State or Province
Zip/Postal Code Country
Apt. #
Mailing Address (if different from home address)
City
Zip/Postal Code Country
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 is domiciled in the United States.
A person who is domiciled in the United States, even if temporarily living outside
the United States.
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)
Form I-800A (02/25/08) 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(s) 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 States Parent(s) Naturalization
Yes No
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)
Yes No
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 (02/25/08) N Page 3
Each of the above questions must be answered. See "Duty of Disclosure" on Page 7 of the instructions to this 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. Please 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(s) 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(s) 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
Divorce Death Other
b. Date Marriage Ended
(mm/dd/yyyy)
How Marriage
Ended
Name of
Prior Spouse
Divorce Death Other
E-mail Address
(if any)
Daytime Phone #
(With Area/Country Code)
Home Phone #
(if different from daytime #)
Yes No
Yes No
Yes No
Yes No
Part 1. Information About You (Continued)
Form I-800A (02/25/08) 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 this 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 (if You Are Married)
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)
Yes No
Yes No
Spouse's Mailing Address (if different from home address)
Home Address - Street Number and Name
City State or Province CountryZip/Postal Code
Apt. #
C/O (in care of)
City State or Province CountryZip/Postal Code
Apt. #
E-mail Address
(if any)
Daytime Phone #
(With Area/Country Code)
1. Date Marriage Ended
(mm/dd/yyyy)
How Marriage
Ended
Divorce Death Other
Form I-800A (02/25/08) 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(s) 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(s) 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
Divorce Death Other
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(s) of
paper. Copies of any relevant documents relating to any other immigration status must be attached to the Form I-800A
application. If your spouse is an alien who does not live in the United States, please provide a complete explanation.)
Birth in the United States Parent(s) Naturalization
Yes No
Yes No
Yes No
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 (if You Are Married) (Continued)
Form I-800A (02/25/08) 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 this 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. Please 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(s) 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.
Yes No
Yes No
Yes No
Part 2. Information About Your Spouse (if You Are Married) (Continued)
Part 3. General Information
Is attached to this application.
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.)
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
City State or Province
Country
Zip/Postal Code
Suite #
Point of Contact (Contact person within the organization)
Daytime Phone # (Area/Country Code)
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 (02/25/08) 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 the Form I-800A is filed because of the operation of State law must be noted and
explained.
4. You plan to: (Select 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(s) 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 a 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(s) 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, please make sure that you have properly completed Item 3 above.)
b.
Yes No
If "Yes," how many?
Yes No
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 (02/25/08) 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 a 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. Please 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 this 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 this 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 this 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 this Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I
am required to disclose.
Yes No
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.)
Form I-800A (02/25/08) 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.
Yes No
Preparer's Address
Date (mm/dd/yyyy)
Preparer's Signature
Preparer's Printed Name Preparer'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)
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 (02/25/08) N
Part 1. Information About an Adult Member of the Household. (You must
complete a 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 this 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.
Please 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(s) of paper.
b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?
Remarks:
START HERE - Please 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 No
Yes No
Yes No
Yes No
Form I-800A, Supplement 1 (02/25/08) 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 this Form I-800A, or to the applicant's adoption service provider, in order to
assist USCIS in adjudicating the Form I-800A.
1. Each answer I have given to each question on this 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 this 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.)
Form I-800A, Supplement 2,
Consent to Disclose Information
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-800A, Supplement 2 (02/25/08) N
I (We) also understand that an adoption service provider 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 is authorized to do so under 8 CFR
part 292. I (We) also understand that the adoption service provider cannot provide any other legal services, unless the adoption
service provider 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.
Remarks:
NOTICE
START HERE - Please Type or Print (Use black ink.)
For USCIS Use Only
Pursuant to the Privacy Act, 5 U.S.C. 552a, and 8 CFR Part 204.302, and in order to assist USCIS in the adjudication of this Form
I-800A, I (we), the undersigned applicant(s) filing this Form I-800A, 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, or which USCIS may obtain as
a result of the collection of my (our) biometrics information, to the following adoption service provider:
I (We) understand that, by signing this supplement, I am (we are) authorizing USCIS to provide the adoption service provider
noted above with copies of notices sent to me (us) about this case, and also to discuss my (our) case with that adoption service
provider.
Your Signature and Printed Name
Signature of Spouse and Printed Name (if you are married)
Provide the below information about your primary adoption service provider who is the 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. If a primary adoption service provider has not yet
been identified, provide the name and address of the adoption service provider who is the accredited agency, as defined in 22 CFR
Part 96.2, who either prepared and approved your home study, or reviewed and approved your home study, or the Public Domestic
Authority who both prepared and approved your home study.
Information that USCIS may have concerning your Form I-800A, Application for
Determination of Suitability to Adopt a Child From a Convention Country, is protected
from disclosure under the Privacy Act, 5 U.S.C. 552a. USCIS generally may not disclose
this information to your adoption service provider without your consent. If you want
USCIS to be able to disclose this information to your adoption service provider, you may
give this consent by signing this Form I-800A, Supplement 2. You do not need to sign
this Form I-800A, Supplement 2, in order to file a Form I-800A
Name of Adoption Service Provider
Point of Contact (Contact person within the organization)
Street Number and Name
City State or Province
E-mail Address (if any)
Country
Zip/Postal Code
Suite #
Date (mm/dd/yyyy) USCIS Account # (if any)
Date (mm/dd/yyyy) USCIS Account # (if any)
Daytime Phone # (Area/Country Code) Fax Number (if any)
Form I-800A, Supplement 3, Request
for Action on Approved Form I-800A
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-800A, Supplement 3 (02/25/08) N
Part 1. Information About You (Person who filed a previously approved Form
I-800A, Application for Determination of Suitability to Adopt a Child from a
Convention Country)
2. I am requesting:
a.
Fill in box if G-28 is attached to
represent the applicant.
Attorney or Representative, if any.
START HERE - Please Type or Print (Use black ink.)
Returned
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
For USCIS Use Only
ATTY State License #
To Be Completed By
1.
Action Block
Continued on next page.
Extension granted to:
New Convention country:
Other change.
(Name of Country)
(Date)
Duplicate approval notice.
Other Names Used (Including maiden name if appropriate)
Family Name (Last Name) Given Name (First Name) Middle Name
State or Province
Home Address - Street Number and Name
City
Zip/Postal Code Country
Apt. #
Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)
Country
E-mail Address (if any)
State or Province
Mailing Address (if different from home address)
City
Zip/Postal Code
Apt. #
C/O (in care of)
Date of Approval
(mm/dd/yyyy)
Date Approval Expires
(mm/dd/yyyy)
USCIS
Receipt #
Location of USCIS Office Where Filed USCIS Account # (if known)
Part 2. Action Requested on Your Previously Approved Form I-800A.
Daytime Phone # (Area/Country Code)
My FIRST extension of the approval of my Form I-800A, and I have not yet
submitted a Form I-800 on behalf of a specific child. If any changes have
occurred, I will indicate such change in Item 3 on the following page. (No fee
required and an updated/amended home study must be submitted.)
A SECOND or SUBSEQUENT extension of the approval of my Form
I-800A, and I have not yet submitted a Form I-800 on behalf of a specific child.
If any changes have occurred, I will indicate such change in Item 3 on the
following page. (An application fee and biometrics fee are required and an
updated/amended home study must be submitted.)
b.
Form I-800A, Supplement 3 (02/25/08) N Page 2
3. Information on changes that have occurred since Form I-800A with supplements (if any) was approved or extended. Check all
boxes that apply. (NOTE: All changes must be fully explained and evaluated in the required updated home study.)
NOTE: For detailed fee information, see "What is the Filing Fee?" on Pages 8 to 10 of the Form I-800A instructions.
Part 2. Action Requested on Your Previously Approved Form I-800A (Continued)
There have been no changes.
History of arrest.
History of sexual abuse.
History of family violence.
History of substance abuse.
History of child abuse or neglect.
Change in Convention country.
Financial status.
Residence.
Marital status. STOP. Do not file this form. You must file a new Form I-800A.
Name of the new Convention country
A new approval notice based on changes in circumstances since my From I-800A was approved, and I am not requesting an
extension, and:
c.
A FIRST TIME change in a Convention country, that was not previously included in my home study recommendation and
my Form I-800A approval notice. I have not yet submitted a Form I-800 on behalf of a specific child. No extension
requested. (No fee required but an amended home study recommending the adoption in the new Convention country must
accompany this application.) NOTE: If requesting both an extension and a change of Convention country, please check
Item 2, a, or 2, b, and also indicate the change in Item 3 below.
A SECOND or SUBSEQUENT change in a Convention country, that was not previously included in my most recent home
study recommendation and my Form I-800A or Form I-800A, Supplement 3 approval notice. I have not yet submitted a
Form I-800 on behalf of a specific child. No extension requested. (The fee must be paid and an amended home study
recommending the adoption in the new Convention country must accompany this application.) NOTE: If requesting both
an extension and a change of Convention country, please check Item 2, a, or 2, b, and also indicate the change in Item 3
below.
A duplicate approval notice. I am not requesting an extension and there has been no change in circumstances since my
Form I-800A was approved. (The fee must be paid.)
d.
e.
f.
1.
I have not yet submitted a Form I-800 on behalf of a specific child; or
2.
I was directed to file this Form I-800A, Supplement 3, by USCIS or U.S. Department of State after filing a Form
I-800 in behalf of a specific child.
Complete Item 3 below. (The fee must be paid and an updated/amended home study must be submitted.)
Form I-800A, Supplement 3 (02/25/08) N Page 3
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 the Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I
am required to disclose.
1. Each answer I have given to each question on this 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:
Your certification:
Change in the number of children or characteristics (such as age, gender, or special needs) of child(ren) you intend to
adopt. (If you add to the number of children you intend to adopt and the children are not already siblings before the
proposed adoption, an additional filing fee will be required when you file the Form I-800 for the second or subsequent child.
For more detailed fee information, see "What is the Filing Fee?" of the Form I-800A instructions.)
Part 2. Action Requested on Your Previously Approved Form I-800A (Continued)
Change in number and/or identity of adult members of the household. (If you check this box, a Form I-800A,
Supplement 1, should be completed and submitted for each new adult member of the household with the required biometrics
fee.)
Change in number and/or identity of children in the household. (Use a separate sheet(s) of paper for additional
children.)
Name
(First/Middle/Last)
Date of Birth
(mm/dd/yyyy)
Country
of Birth
A #
(if applicable)
Relationship to You
(if any)
Other. (If you checked this box, provide additional information about the change(s). If you need more space to complete,
use a separate sheet(s) 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. Certification and Signature of You, the Prospective Adoptive Parent(s) (Read the information on penalties in the
instructions before completing this section.)
Your Signature
Date (mm/dd/yyyy)
Form I-800A, Supplement 3 (02/25/08) N Page 4
Fax Number
(With Area Code)
Attorney or Representative Only:
In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
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.
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 the Form I-800A.
ALSO: If you had assistance in filling out this application, the person preparing the form must complete Part 4. 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.
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.
I certify, under penalty of perjury under the laws of the United States, that:
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 the Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I
am required to disclose.
1. Each answer I have given to each question on this Form I-800A and attached supplement(s) is true and correct to the best of my
knowledge, information, and belief; and
Certification of your spouse (if you are married):
Part 3. Certification and Signature of You, the Prospective Adoptive Parent(s) (Continued)
Date (mm/dd/yyyy)
Signature of Spouse
Part 4. Signature of Person Preparing Form if Other Than Above (Sign below)
Preparer's Firm Name (if applicable)
Yes No
Preparer's Address
Date (mm/dd/yyyy)
Preparer's Signature
Preparer's Printed Name
E-mail Address
(if any)
Daytime Phone Number
(With Area Code)
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Completed 9 January 2021

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