Form I-800, Petition to Classify Convention Adoptee as an Immediate Relative Department of Homeland Security U.S. Citizenship and Immigration Services START HERE - Type or Print (Use black ink) Part 1. Information About You (Person filing this petition) Returned NOTICE Date You may not submit Form I-800 if there have been certain changes in your circumstances since your last home study was completed and your Form I-800A, Application for Determination of Suitability to Adopt a Child from a Convention Country, was last approved or extended. If there has been a change, STOP. See instructions for Form I-800 for more information on the type of changes requiring the filing of a new Form I-800A or Form I-800A, Supplement 3. NOTE: If you need more space to complete an answer, use a separate sheet of paper. Write your name, your USCIS Account Number, and the child's current legal name at the top of each sheet of paper and indicate the part and number of the item to which the answer refers. 1. Provide the following information about yourself: Family Name (Last Name) Given Name (First Name) Date of Birth (mm/dd/yyyy) Date Resubmitted Date Date Reloc Sent Date Date Reloc Rec'd Date Middle Name Date Other Names Used (including maiden name if appropriate) USCIS Account # For Official Use Only Receipt U.S. Social Security # (if any) Place of Birth (City/Town, State/Province, Country) Home Address - Street Number and Name Apt. # 1. The petition is provisionally approved for a Convention Adoptee who will be: Adopted Coming to the U.S. for abroad. adoption. Preadoption requirements met. 2. The child will seek: IV. NIV, so as to apply for naturalization under Sec. 322 after lawful admission. Adjustment of Status under Sec. 245. 3. The petitioner is: Married Unmarried Provisional Action Block: City State or Province Zip/Postal Code Country Mailing Address (if different from home address) Apt. # C/O (in care of) City State or Province Final Action Block: Child's legal name after adoption: Zip/Postal Code Country Contact Information: Daytime Phone # (with area/country code) E-Mail Address (if any) 2. Is the daytime phone number the same as the one provided on Form I-800A? Yes No 3. Is the e-mail address (if any) the same as the one provided on Form I-800A? Yes No Officer Signature Date To Be Completed By Attorney or Representative, if any. Check if G-28 is attached. ATTY State License # Form I-800 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com Part 1. Information About You (Continued) 4. If you are married, complete "a" and "b" below. a. Provide the following information about your spouse: Family Name (Last Name) Given Name (First Name) USCIS Account # U.S. Social Security # (if any) Date of Birth (mm/dd/yyyy) Middle Name Place of Birth (City/Town, State/Province, Country) b. 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 petition unless your spouse will join in the submission of Form I-800 and the adoption of the child. Home Address - Street Number and Name Apt. # City State or Province Zip/Postal Code Country Mailing Address (if different from home address) Apt. # C/O (in care of) City Contact Information: Daytime Phone # (with area/country code) State or Province Zip/Postal Code Country E-Mail Address (if any) Part 2. Processing Information 1. Provide the following information on your previously approved Form I-800A. Date of Approval USCIS (mm/dd/yyyy): Receipt # Date Approval/Extension Expires (mm/dd/yyyy) 2. Check "a," "b," or "c." (If none of the below options apply, STOP. You cannot file this petition.) a. The child will seek an immigrant visa, if Form I-800 is approved, because the child will reside in the United States with me, the U.S. citizen petitioner, after the child's admission to the United States on the basis of the proposed adoption. NOTE: If you, the U.S. citizen petitioner, are domiciled in the United States, but are posted abroad temporarily under official orders as a member of the Uniformed Services as defined in 5 U.S.C. 2101, or as a civilian officer or employee of the U.S. Government, the child will be deemed to be coming to the United States to reside in the United States with you, the U.S. citizen petitioner. b. The child will seek a nonimmigrant visa, in order to travel to the United States to obtain naturalization under section 322 of the Immigration and Nationality Act (INA), because I (we), the U.S. citizen petitioner and spouse (if married), intend to complete the adoption abroad, and I (we) will continue to reside abroad with the child immediately following the adoption, rather than residing in the United States. NOTE: This option is not available if the child will be adopted in the United States. You must complete the adoption abroad to use this option. Form I-800 (Rev. 11/23/10) Y Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. Processing Information c. (Continued) The child will seek adjustment of status because the child is already present in the United States in a status that does not preclude the child’s adjustment of status, and I (we), the U.S. citizen petitioner and spouse (if married), will either adopt the child in the country of the child’s habitual residence or adopt the child in the United States after obtaining custody of the child in that country for purposes of emigration and adoption. NOTE: This option is not available if the country of the child’s habitual residence requires the child's return to that country in order for the U.S. citizen petitioner to adopt or obtain custody of the child. 3. If you checked Item 2, a, or Item 2, b, provide the location of the U.S. Embassy or consulate outside the United States where you intend to submit the child's application for a visa. City in Foreign Country Foreign Country 4. Are you filing more than one Form I-800 on behalf of a child from a Convention Country within the validity period of your approved I-800A? If "Yes," go to Question 5. Yes No 5. If you are filing more than one Form I-800, are the children already siblings prior to the proposed adoption? Yes No (If more than one Form I-800 is filed during the approval period for different children, a fee is required for the second and each subsequent Form I-800. However, if the children are siblings, no additional filing fee is required. For more detailed information, see "What is the Filing Fee?" of Form I-800A instructions.) Part 3. Information About the Beneficiary (Convention adoptee) 1. Give the following information about the child's current name. Family Name (Last Name) Given Name (First Name) Middle Name 2. Give the following information about the child's name at the time of birth, if known. Family Name (Last Name) Given Name (First Name) Middle Name 3. Give any other name that the child is or was known as: Family Name (Last Name) Given Name (First Name) Middle Name 4. Give the following information about the child's birth. Date of Birth (mm/dd/yyyy) Place of Birth (City/Town, State/Province, Country) Gender Male Female 5. Give the name of the country in which the child is a habitual resident (as provided for in 8 CFR Part 204.303). 6. Who is currently the legal custodian of the child? Form I-800 (Rev. (Rev. 11/23/10) Y Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Information About the Beneficiary (Continued) 7. The child’s legal custodian is (Check only one box): An individual or entity other than the child’s birth parents. (This includes any child welfare agency, orphanage, or other individual or entity that has custody of the child, a legal guardian, or any person(s) who is (are) the child’s parent(s) based on a prior adoption.) The child’s living birth parents, each of whom has consented to the adoption and who are incapable of providing proper care to the child. The child’s surviving birth parent, because the other birth parent is dead, and the child has not acquired another parent (as defined in 8 CFR Part 204.301). The child’s sole birth parent, because the competent authority has determined that the child's other birth parent has abandoned or deserted the child, or has disappeared from the child’s life, and the child has not acquired another parent (as defined in 8 CFR Part 204.301). 8. The child will reside with me (Choose one): a. In the United States at the following address: Street Number and Name City b. State Zip Code Outside the United States at the following address: (The child will seek a nonimmigrant visa, in order to travel to the United States to obtain citizenship under section 322 of the Immigration and Nationality Act (INA)). Street Number and Name City State or Province Zip/Postal Code Country 9. Are you submitting with Form I-800: a. The report as required under Article 16 of the Convention? (See Form I-800 instructions, Pages 4 to 5, for information on Article 16 report.) Yes No b. The child's background information as provided for under 22 CFR Part 96.49? (See Form I-800 instructions, Pages 4 to 5, for information on 22 CFR Part 96.49.) Yes No 10. If you answered "No" to either Question 9, a, or Question 9, b, was this because the Central Authority of the child's country of habitual residence placed the child for adoption more than 6 months after the child's 15th birthday but before the child's 16th birthday, and the report that must accompany Form I-800 is not yet available? Yes No 11. If you answered "Yes" to Question 10, are you submitting a declaration from the primary provider, signed under penalty of perjury, verifying that the Central Authority did in fact make the decision to place the child for adoption before the child's 16th birthday? If you answered "Yes" to Question 10 and Questions 11, go to Question 16. Yes No If "Yes," to either 9, a, or 9, b, go to Question 12. Form I-800 (Rev. 11/23/10) Y Page 4 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Information About the Beneficiary (Continued) 12. The Article 16 report is accompanied by: a. A copy of the child's birth certificate or secondary evidence of the child's age. Yes No b. A copy of the irrevocable consent(s) signed by the legal custodian(s) identified in Item 6, and any other individual or entity who must consent to the child's adoption (or, if the law of the country of the child's habitual residence provides that their identities may not be disclosed, the Central Authority's certification that the required documents exist and that they establish the child's age and availability for adoption). Yes No c. A statement, signed under penalty of perjury by the primary provider (or an authorized representative if the primary provider is an agency or other juridical person), certifying that the report is a true, correct, and complete copy of the report obtained from the Central Authority of the Convention country. Yes No 13. The Article 16 report or child's background information includes evidence/verification of one of the following as it relates to the child you intend to adopt and the child's legal custodian: (You must select one box unless one or both of the report(s) are not yet available and you responded "Yes" to both Item 10 and Item 11.) a. If the legal custodian is an individual or entity other than the child’s birth parents, the legal basis of custody and the circumstances leading to the grant of custody. b. If the legal custodians are both the child’s birth parents, the factual basis for concluding that they are incapable of providing proper care. c. If the legal custodian is the child’s surviving birth parent, proof of the other birth parent’s death. d. If the legal custodian is one of the child’s birth parents, verification of the circumstances leading to the competent authority’s determination that the other birth parent has abandoned or deserted the child, or has disappeared from the child’s life. NOTE: A copy of any irrevocable consent signed by the legal custodian(s) and any other individual or entity that must consent to the child's adoption must be submitted with the petition unless the law of the country of the child's habitual residence provides that their identities may not be disclosed. In that case, the Central Authority's certification that the required documents exist and they establish the child's age and availability for adoption must be submitted. 14. Does the child's background information include a statement concerning whether, from any examination (as described in 22 CFR Part 96.49(e)) or for any other reason, there is reason to believe that the child has any medical condition that makes the child inadmissible under section 212(a)(1) of the INA? (NOTE: For information on medical inadmissibility issues, see Page 5 of Form I-800 instructions.) Yes No 15. Are you filing Form I-601, Application for Waiver of Grounds of Inadmissibility, with Form I-800? (NOTE: This is not limited to medical inadmissibility, but may be for any ground of inadmissibility that may apply to the child and for which a waiver is available. If you do not file the waiver application with Form I-800, you may have to file it later in order for the child to be able to immigrate.) Yes No 16. Have you or your spouse (if married) had any contact with the parent(s), legal custodian, or other individual or entity responsible for the care of the child you are seeking to adopt? If "No," go to Question 18. Yes No 17. If your answer to Question 16 is "Yes," check each block that applies to your case: a. The first contact occurred after USCIS approved my Form I-800A and after the Central Authority of the child's country determined that the child was eligible for intercountry adoption. The date of this first contact was: b. The Central Authority of the child's country of habitual residence permitted the earlier contact. (You must include a statement from the Central Authority of the child's country establishing this claim.) Form I-800 (Rev. 11/23/10) Y Page 5 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Information About the Beneficiary (Continued) c. I am or my spouse (if married) is already related to the child's parent(s) or legal custodian (as specified in 8 CFR Part 204.309(b)(2)(iii)). I am or my spouse (if married) is related to the child's parent(s) or legal custodian in the following manner: d. Neither Box "a," nor Box "b," nor Box "c" applies to my case. If you check Box "d," give the date and circumstances regarding any contact with the parent(s) or legal custodian of the child you are seeking to adopt. 18. Have you already adopted the child or have you or an individual or entity acting on your behalf obtained custody of the child for purposes of the child's emigration and adoption in the United States? If "No," go to Question 20. Yes No 19. If your answer to Question 18 is "Yes," has the adoption or custody order been vacated, annulled, or otherwise terminated so that the order no longer has any legal effect, and you and your spouse (if married) will adopt the child anew after complying with the requirements of the Convention? (If "No," STOP. You may not file this petition, and it cannot be approved unless the order is vacated, annulled, or otherwise terminated so that you may adopt the child after complying with the requirements of the Convention.) Yes No 20. My spouse and I jointly (if married), or I, as the unmarried petitioner: a. Intend to adopt the child in the Convention country. If you check this box, go to Item 22. b. Intend to adopt the child in the United States after acquiring custody of the child in the Convention country. If you check this box, go to Item 21. 21. If you selected Item 20, b, have the preadoption requirements, if any, of the child's proposed State of residence been met? Yes No a. If your answer is "Yes," name the State of the child's proposed residence and describe the preadoption requirements that have been met. b. If your answer is "No," will the preadoption requirements be met at a later date? If your answer is "Yes," describe the requirements and indicate when the preadoption requirements will be met. Form I-800 (Rev. 11/23/10) Y Page 6 American LegalNet, Inc. www.FormsWorkFlow.com Part 3. Information About the Beneficiary (Continued) 22. Name and address of your primary adoption service provider in the United States. (Your primary adoption service provider 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.) Name of Primary Adoption Service Provider Point of Contact (contact person within the organization) Street Number and Name City Phone Number (with area code) State Fax Number (with area code) Zip Code E-Mail Address (if any) The above named primary adoption service provider is one of the following: a. An accredited or temporarily accredited agency in the United States. Yes No b. An approved person in the United States. Yes No 23. Does the primary adoption service provider's statement (as provided for in 22 CFR Part 96.48) verifying that all pre-placement counseling has been completed, accompany Form I-800? Yes No 24. If the child will be adopted in the United States, do you have the primary adoption service provider's written report, signed under penalty of perjury by the primary adoption service provider (or an authorized representative if the primary adoption service provider is an agency or other juridical person) detailing the primary adoption service provider's plan for post-placement duties (as specified in 22 CFR Part 96.50)? Yes No Not applicable (Child will be adopted outside United States) 25. Give the following information about the person with whom or institution where the child is currently living. Name of Person or Institution Street Number and Name City/Town State or Province Phone Number (with area/country code) Country Zip/Postal Code 26. If the child is living with a person and not living in an institution, provide information about the person's relationship to the child: 27. Select which of the following you are filing with your Form I-800: a. A properly completed Form I-864, Affidavit of Support Under Section 213A of the Act; OR Yes No b. A properly completed Form I-864W, Intending Immigrant's Affidavit of Support Exemption. Yes No Form I-800 (Rev. 11/23/10) Y Page 7 American LegalNet, Inc. www.FormsWorkFlow.com Part 4. Information About Fees, Expenses and Other Compensation 1. Information on payments already made: As of the date of the signing of Form I-800, I (or, for a married petitioner, we) have made the following payments, including in-kind contributions, in relation to the adoption of the child identified in Form I-800. The following table includes all fees, expenses, in-kind contributions, and other compensation that I (we) have made, either directly or indirectly, to any individual, agency, entity, governmental authority, or other payee or recipient. Date (mm/dd/yyyy) Payee Relationship to Child (if any) Purpose of Payment Amount of payment (or description and value of in kind consideration) 2. Information on anticipated future payments: The following table includes all fees, expenses, in kind contributions, and other compensation as of the date of the signing of Form I-800, that I (we) reasonably expect to make, either directly or indirectly, to any individual, agency, entity, governmental authority, or other payee or recipient. Anticipated Date Payee of Payment (mm/dd/yyyy) Relationship to Child (if any) Purpose of Payment Amount of payment (or description and value of in kind consideration) NOTE: If you need more space to complete Item 1 and Item 2, use a separate sheet of paper. Follow the same format as the above tables. Write your name, your USCIS Account Number, and the child's current legal name at the top of each sheet of paper and indicate the part and number of the item to which the answer refers. Form I-800 (Rev. 11/23/10) Y Page 8 American LegalNet, Inc. www.FormsWorkFlow.com Part 5. 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-800 is true and correct to the best of my knowledge, information, and belief; and 2. That I (and my spouse, if married) have not paid, given, or transferred any money or any other thing of value to any individual or entity as compensation or inducement for that person’s consent to the child’s adoption, and I (and my spouse, if married) have not authorized, permitted, or in any way condoned any such payment, gift, or transfer by any individual or entity acting on my (or our) behalf. 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-800 is true and correct to the best of my knowledge, information, and belief; and 2. That my spouse and I have not paid, given, or transferred any money or any other thing of value to any individual or entity as compensation or inducement for that person’s consent to the child’s adoption, and we have not authorized, permitted, or in any way condoned any such payment, gift, or transfer by any individual or entity acting on my (or our) behalf. 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 petition will be denied. NOTICE: If you want to give consent for USCIS to disclose information about your case to your primary adoption service provider, you must complete Form I-800, Supplement 1, Consent to Disclose Information. You are not required to give this consent in order to file Form I-800. ALSO: If you had assistance in filling out this petition, the person preparing the form must complete Part 6. 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 6. Signature of Person Preparing Form if Other Than Above (Sign below) I declare that I prepared this petition 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 petition. 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-800 (Rev. 11/23/09) Y Page 9 American LegalNet, Inc. www.FormsWorkFlow.com Form I-800, Supplement 1, 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-800, Petition to Classify Convention Adoptee as an Immediate Relative, 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 primary adoption service provider, you may give this consent by signing Form I-800, Supplement 1. You do not need to sign Form I-800, Supplement 1, in order to file Form I-800. Note: Your primary adoption service provider 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. Pursuant to the Privacy Act, 5 U.S.C. 552a, and 8 CFR 204.302, and in order to assist USCIS in the adjudication of Form I-800, I (we), the undersigned petitioner(s) filing Form I-800, 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 primary adoption service provider: Name of Primary 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 primary adoption service provider noted above with copies of notices sent to me (us) about this case, and also to discuss all aspects of my (our) case, including the prior Form I-800A proceeding as well as this Form I-800 proceeding. 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. SPECIFY whether you are withdrawing the consent to disclosure that you gave on a prior Form I-800A, Supplement 2, Consent to Disclose Information, or Form I-800, Supplement 1, Consent to Disclose Information: Yes, I am (we are) withdrawing all prior consents to disclose. No, USCIS may continue to disclose information to any adoption service provider included on any prior Form I-800A, Supplement 2, or Form I-800, Supplement 1. 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-800, Supplement 1 (Rev. 11/23/10) Y American LegalNet, Inc. www.FormsWorkFlow.com