Department of Homeland Security U.S. Citizenship and Immigration Services Form I-800A, Application for Determination of Suitability to Adopt a Child from a Convention Country START HERE - Type or Print (Use black ink) Part 1. For USCIS Use Only Receipt Returned Information About You (Person filing this application) 1. Provide the following information about yourself: Family Name (Last Name) Given Name (First Name) Date Middle Name Date Resubmitted Other Names Used (including maiden name if appropriate) Date USCIS Account # Date of Birth (mm/dd/yyyy) U.S. Social Security # (if any) Date Reloc Sent Place of Birth (City/Town, State/Province, Country) Date Home Address - Street Number and Name City Apt. # Date Reloc Rec'd State or Province Date Zip/Postal Code Country Date This application was filed by: Mailing Address (if different from home address) Apt. # A Married Applicant An Unmarried Applicant C/O (in care of) City State or Province Zip/Postal Code This application is approved for a Convention adoptee from: Country (Name of Convention Country) Period of approval valid until: 2. I intend to adopt a child habitually residing in the following Convention country: (Date) Action Block 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. 3. I am a habitual resident of the United States as: 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 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. To Be Completed By Attorney or Representative, if any. Fill in box if G-28 is attached to represent the applicant. ATTY State License # Form I-800A (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Part 1. Information About You (Continued) 4. I am: A citizen of the United States. I obtained my U.S. citizenship through: Birth in the United States Parent(s) Naturalization 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). 5. If you derived or acquired citizenship through your parent(s), have you obtained your own certificate of citizenship? Yes No Yes No If "Yes," provide the following information: Name Under Which Certificate of Citizenship Was Issued Certificate of Citizenship Number Date of Issuance (mm/dd/yyyy) Place of Issuance A# (if known) 6. If you became a citizen by naturalization, give the following information: Name Under Which Certificate of Naturalization Was Issued Naturalization Certificate Number Date of Naturalization (mm/dd/yyyy) Place of Naturalization A# (if known) 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. 8. Provide the following information about your current marital status. a. I am: Single, never married. Single, with all previous marriages terminated. (If you check this box, you must complete 8,c.) Married, with no previous marriages. (If you check this box, you must complete 8,b.) Married, with all previous marriages terminated. (If you check this box, you must complete 8,b, and c.) b. If married, provide the following information: Date of Current Marriage (mm/dd/yyyy) Place of Current Marriage (City/Town, State/Province, Country) Form I-800A (Rev. 11/23/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 1. Information About You (Continued) c. Information on all previous marriages, if applicable. Begin with the most recent termination. 1. Number of Previous Marriages (Do not count current marriage) 2. Provide the following information on each terminated marriage (if applicable): a. Date Marriage Ended Name of (mm/dd/yyyy) Prior Spouse How Marriage Ended Divorce b. Date Marriage Ended Name of (mm/dd/yyyy) Prior Spouse Death Other Death Other How Marriage Ended Divorce 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. 9. My contact information is (all phone numbers must include area code and country code, if applicable): Daytime Phone # (with area/country code) Home Phone # (if different from daytime #) E-Mail Address (if any) 10. Have you ever, 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? Yes No b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? Yes No 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? Yes No 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? Yes No 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. Form I-800A (Rev. 11/23/10) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Information About Your Spouse 1. If you are married, provide the following information about your spouse: Family Name (Last Name) Given Name (First Name) Middle Name Other Names Used (including maiden name if appropriate) Date of Birth (mm/dd/yyyy) Place of Birth (City/Town, State/Province, Country) U.S. Social Security # (if any) A # (if any) USCIS Account # (if any) 2. Does your spouse reside with you? Yes No 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. Home Address - Street Number and Name City Apt. # State or Province Zip/Postal Code Country Spouse's Mailing Address (if different from home address) Apt. # C/O (in care of) City State or Province Zip/Postal Code Country Spouse's Contact Information Daytime Phone # (with area/country code) E-Mail Address (if any) 3. Prior to your current marriage, has your spouse been previously married? Yes No If "Yes," provide the following information. Begin with the most recent termination. a. Number of Previous Marriages (Do not count current marriage) b. Provide the following information on each terminated marriage (if applicable): 1. Date Marriage Ended (mm/dd/yyyy) Name of Prior Spouse How Marriage Ended Divorce Death Other Form I-800A (Rev. 11/23/10) Y Page 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Information About Your Spouse 2. Date Marriage Ended (mm/dd/yyyy) (Continued) Name of Prior Spouse How Marriage Ended Divorce Death Other 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: Is a citizen of the United States through: Birth in the United States Parent(s) Naturalization 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.) 5. If your spouse derived citizenship through his or her parent(s), has he or she obtained his or her own certificate of citizenship? Yes No Yes No Yes No If "Yes," provide the following information: Name Under Which Certificate of Citizenship Was Issued Certificate of Citizenship Number Date of Issuance (mm/dd/yyyy) Place of Issuance A# (if known) 6. If your spouse became a citizen by naturalization, give the following information: Name Under Which Certificate of Naturalization Was Issued Naturalization Certificate Number Date of Naturalization (mm/dd/yyyy) Place of Naturalization A# (if known) 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: 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? Form I-800A (Rev. 11/23/10) Y Page 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Information About Your Spouse (Continued) b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? Yes No 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? Yes No 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? Yes No 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. Part 3. General Information 1. The home study: 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.) 2. Name and Address of Adoption Service Provider. Provide the name and address of either (Check one): a. 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 b. 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.) Name of Adoption Service Provider Point of Contact (contact person within the organization) Daytime Phone # (with area/country code) Street Number and Name City Suite # State or Province Zip/Postal Code Country Form I-800A (Rev. 11/23/10) Y Page 6 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. General Information (Continued) 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. 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. You plan to (Check one): a. Complete the proposed adoption in the Convention country. b. 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.) 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.) Yes If "Yes," how many? No 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? Yes No 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. Approved - Approval Date (mm/dd/yyyy): Denied - Denial Date (mm/dd/yyyy): NOTE: A copy of the written denial notice must accompany this application. Other - Explain: 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. Form I-800A (Rev. 11/23/10) Y Page 7 American LegalNet, Inc. www.FormsWorkFlow.com 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. Yes No 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. Name (First/Middle/Last) Date of Birth (mm/dd/yyyy) Country of Birth A# (if applicable) Relationship to You (if any) Part 4. Certification and Signature of You, the Prospective Adoptive Parent(s) (Read the information on penalties in the instructions before completing this section.) Your certification: 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 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 Date (mm/dd/yyyy) Certification of your spouse (if you are married): 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 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. Signature of Spouse Date (mm/dd/yyyy) 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. Form I-800A (Rev. 11/23/10) Y Page 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 4. Certification and Signature of You, the Prospective Adoptive Parent(s) (Continued) 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. 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. Part 5. Signature of Person Preparing Form if Other Than Above (Sign below) 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? Yes Preparer's Signature No Date (mm/dd/yyyy) Preparer's Printed Name Preparer's Firm Name (if applicable) Preparer's Address Daytime Phone Number (with area code) Fax Number (with area code) E-Mail Address (if any) Form I-800A (Rev. 11/23/10) Y Page 9 American LegalNet, Inc. www.FormsWorkFlow.com Form I-800A, Supplement 1, Listing of Adult Member of the Household Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or Print (Use black ink) For USCIS Use Only Part 1. Information About an Adult Member of the Household. (You must Remarks: 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. 1. Provide the following information about the adult member of the household: Family Name (Last Name) Given Name (First Name) Middle Name Other Names Used (including maiden name if appropriate) Date of Birth (mm/dd/yyyy) A # (if any) Place of Birth (City/Town, State/Province, Country) U.S. Social Security # (if any) Mailing Address Apt. # C/O (in care of) City State or Province Zip/Postal Code Country 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? Yes No b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? Yes No 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? Yes No 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? Yes No 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. Form I-800A, Supplement 1 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com 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.) 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. Your Signature (Applicant) Date (mm/dd/yyyy) Applicant Family Name (Last Name) Applicant Given Name (First Name) Applicant Middle Name Other Names Used (including maiden name if appropriate) Date of Birth (mm/dd/yyyy) U.S. Social Security # (if any) Place of Birth (City/Town, State/Province, Country) A # (if any) USCIS Account # (if any) Certification of the adult member of the household: 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 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. 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. Adult Member of the Household's Signature Daytime Phone Number (with area code) Date (mm/dd/yyyy) E-Mail Address (if any) Form I-800A, Supplement 1 (Rev. 11/23/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Form I-800A, Supplement 2, Consent to Disclose Information Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or Print (Use black ink) For USCIS Use Only Remarks: NOTICE 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 Form I-800A, Supplement 2. You do not need to sign Form I-800A, Supplement 2, in order to file Form I-800A 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. 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 Form I-800A, I (we), the undersigned applicant(s) filing 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: Name of Adoption Service Provider Point of Contact (contact person within the organization) Street Number and Name City Suite # State or Province Daytime Phone # (with area/country code) Fax Number (if any) Zip/Postal Code Country E-Mail Address (if any) 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. 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. Your Signature and Printed Name Date (mm/dd/yyyy) USCIS Account # (if any) Signature of Spouse and Printed Name (if you are married) Date (mm/dd/yyyy) USCIS Account # (if any) Form I-800A, Supplement 2 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Form I-800A, Supplement 3, Request for Action on Approved Form I-800A Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or Print (Use black ink) For USCIS Use Only 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) Family Name (Last Name) Given Name (First Name) Middle Name Receipt Returned Date Date Resubmitted Other Names Used (including maiden name if appropriate) Date Date of Birth (mm/dd/yyyy) Place of Birth (City/Town, State/Province, Country) Home Address - Street Number and Name Apt. # City State or Province Zip/Postal Code Date Reloc Sent Date Country Date Reloc Rec'd Date Mailing Address (if different from home address) Apt. # Extension granted to: C/O (in care of) City (Date) State or Province New Convention country: Zip/Postal Code Country (Name of Country) Daytime Phone # (with area/country code) E-Mail Address (if any) Other change. Duplicate approval notice. Part 2. Action Requested on Your Previously Approved Form I-800A 1. USCIS Receipt # Date of Approval (mm/dd/yyyy) Location of USCIS Office Where Filed Date Approval Expires (mm/dd/yyyy) Action Block USCIS Account # (if known) 2. I am requesting: a. My FIRST extension of the approval of my Form I-800A, and I have not yet submitted 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 is required and an updated/amended home study must be submitted.) b. A SECOND or SUBSEQUENT extension of the approval of my Form I-800A, and I have not yet submitted 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.) To Be Completed By Attorney or Representative, if any. Fill in box if G-28 is attached to represent the applicant. ATTY State License # Continued on next page. Form I-800A, Supplement 3 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Action Requested on Your Previously Approved Form I-800A c. (Continued) A new approval notice based on changes in circumstances since my From I-800A was approved, and I am not requesting an extension, and: 1. I have not yet submitted Form I-800 on behalf of a specific child; or 2. I was directed to file Form I-800A, Supplement 3, by USCIS or U.S. Department of State after filing 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.) d. 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 Form I-800 on behalf of a specific child. No extension requested. (No fee is 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, check Item 2, a, or 2, b, and also indicate the change in Item 3 below. e. 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 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, check Item 2, a, or 2, b, and also indicate the change in Item 3 below. f. 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.) NOTE: For detailed fee information, see "What is the Filing Fee?" on Pages 8 to 10 of the Form I-800A instructions. 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.) There have been no changes. Marital status. STOP. Do not file this form. You must file a new Form I-800A. Residence. Financial status. Change in Convention country. Name of the new Convention country History of arrest. History of child abuse or neglect. History of substance abuse. History of family violence. History of sexual abuse. Form I-800A, Supplement 3 (Rev. 11/23/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Action Requested on Your Previously Approved Form I-800A (Continued) 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 Form I-800 for the second or subsequent child. For more detailed fee information, see "What is the Filing Fee?" of Form I-800A instructions.) Change in number and/or identity of adult members of the household. (If you check this box, 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 of paper for additional children.) Name (First/Middle/Last) Date of Birth Country (mm/dd/yyyy) 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 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 certification: 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 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 Date (mm/dd/yyyy) Form I-800A, Supplement 3 (Rev. 11/23/10) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Certification and Signature of You, the Prospective Adoptive Parent(s) (Continued) Certification of your spouse (if you are married): 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 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. Signature of Spouse Date (mm/dd/yyyy) 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. 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. 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. Part 4. Signature of Person Preparing Form if Other Than Above (Sign below) 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? Yes No Preparer's Signature Date (mm/dd/yyyy) Preparer's Printed Name Preparer's Firm Name (if applicable) Preparer's Address Daytime Phone Number (with area code) Fax Number (with area code) E-mail Address (if any) Form I-800A, Supplement 3 (Rev. 11/23/10) Y Page 4 American LegalNet, Inc. www.FormsWorkFlow.com