Supplement 1, Listing of Adult Member of the Household Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-600A/I-600 Supplement 1 OMB No. 1615-0028 Expires 12/31/2018 Part 1. Information About an Adult Member of the Household You must complete Form I-600A/Form I-600, Supplement 1, for each adult member of your household 18 years of age or older. Note you do not need to complete one for yourself or your spouse (if married). Provide the following information about the Adult Member of the Household: 1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 2. Other Names You Have Used (including maiden name, nicknames, and aliases, if any) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 3. U.S. Mailing Address (if any) In Care Of Name Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 4. Is your current U.S. mailing address the same as your U.S. physical address? Yes No If you answered "No" to Item Number 4., provide your U.S. physical address in Item Number 5. or your address abroad in Item Number 6., as appropriate. 5. U.S. Physical Address (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 6. Address Abroad (if any) Street Number and Name Apt. Ste. Flr. Number City or Town State Province Postal Code Country 7. Date of Birth (mm/dd/yyyy) 8. City/Town/Village of Birth Form I-600A/I-600 Supplement 1 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 Part 1. Information About an Adult Member of the Household (continued) 9. State or Province of Birth 10. Country of Birth 11. Alien Registration Number (A-Number) (if any) A- Duty of Disclosure You must answer each of the following questions. See the Duty of Disclosure section in the Form I-600A or Form I-600 instructions, concerning your ongoing duty to disclose information in response to these questions. If you answer "Yes" to any of these 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; and 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; type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 12. Has the adult member of the household 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, even if the record of the arrest, conviction, or other adverse criminal history was expunged, sealed, pardoned, or the subject of any other amelioration? 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? 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 Yes Yes No No Yes No Part 2. Information About You (Applicant or Petitioner Filing Form I-600A/I-600) 1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 2. Date of Birth (mm/dd/yyyy) 3. City/Town/Village of Birth 4. State or Province of Birth 5. Country of Birth 6. Alien Registration Number (A-Number) (if any) A- Form I-600A/I-600 Supplement 1 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Part 3. Adult Member of the Household's Statement, Contact Information, Certification, and Signature Adult Member of the Household's Statement Select the box for either Item Number 1.A. or 1.B. If applicable, select the box for Item Number 2. 1.A. 1.B. I can read and understand English, and have read and understand every question and instruction on this supplement, as well as my answer to every question. The interpreter named in Part 6. has read to me every question and instruction on this supplement, as well as my answer to every question, in , a language in which I am fluent. I understand every question and instruction on this supplement as translated to me by my interpreter, and have provided complete, true, and correct responses. 2. I have requested the services of and consented to who is is not an attorney or accredited representative, preparing this supplement for me. , Adult Member of the Household's Contact Information 3. Adult Member of the Household's Daytime Telephone Number 4. Adult Member of the Household's Mobile Telephone Number (if any) 5. Adult Member of the Household's Email Address (if any) Adult Member of the Household's Certification Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any and all of my records that USCIS may need to determine the suitability and eligibility of the applicant or petitioner as an adoptive parent. I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records to other entities and persons where necessary for the administratio