Supp 1 TOC

Supplement 1,

Listing of Adult Member of the Household

Form I-600A/I-600,

OMB RIN: 1615-0028

812/2617/2014

Reason for Revision:

Location	Current Text	Proposed Text
Page 1, Part 1. Information About an Adult Member of the Household	Information About an Adult Member of the Household A Form I-600A/Form I-600, Supplement 1, must be completed and submitted for every adult member of the household age 18 and older who lives in the home of the prospective adoptive parent(s) except for the spouse of the applicant/petitioner. If there are multiple adult members of the household, please submit multiple copies of this page. Notice to the Adult Member of the Household: By signing this page you are providing your consent to permit USCIS to disclose to the applicant/petitioner or the applicant's/petitioner's adoption service provider information that users may obtain about you that is relevant to the adjudication of the applicant's petition or application. Provide the following information about the adult member of the household: 1.a. Family Name (Last Name) 2.b. Given Name (First Name) 2.c. Middle Name 3. Date of Birth (mm/dd/yyyy) 4.a. City/Town of Birth 4.b. State/Province of Birth 4.c. Country of Birth 5. A-Number (if any)	Page 1, 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: Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) 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) U.S. Mailing Address (if any) In Care Of Name Street Number and Name Apt. Ste. Flr. Number City or Town State ZIP Code 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) City/Town/Village of Birth State or Province of Birth Country of Birth Alien Registration Number (A-Number) (if any) 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. Has the adult member of the household EVER, whether in or outside the United States: 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? __ Yes __ No Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? __ Yes __ No 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 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
		Page 2, Part 2. Information About You (Applicant or Petitioner Filing Form I-600A/I-600) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) Date of Birth (mm/dd/yyyy) City/Town/Village of Birth State or Province of Birth Country of Birth Alien Registration Number (A-Number, if any)
Page 1, Part 2. Certification of the Adult Member of the Household	Part 2. 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 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 and I agree to notify the applicant/ petitioner of any new information that I am required to disclose. Pursuant to the Privacy Act, 5 USC 552a, I also authorize USCIS to disclose information about me which may appear in any system of records maintained by the US 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, or to the adoption service provider of the applicant(s), in order to assist USCIS in adjudicating this form.	Page 3, Part 3. Adult Member of the Household’s Statement, Certification, Signature, and Contact Information 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. [Check Box] I can read and understand English, and have read and understand each and every question and instruction on this supplement, as well as my answer to each question. 1.B.  [Check Box] The interpreter named in Part 6. has read to me each and every question and instruction on this supplement, as well as my answer to each question, in [Fillable Field], a language in which I am fluent. I understand each and 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 [Fillable Field], who is __is not __an attorney or accredited representative, preparing this supplement for me. Adult Member of the Household’s Certification I certify, under penalty of perjury under the laws of the United States of America, that the information in my supplement and any document submitted with my supplement is complete, true, and correct. 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 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 administration of U.S. immigration laws. Adult Member of the Household’s Signature 3. Adult Member of the Household’s Signature Date of Signature (mm/dd/yyyy)  Adult Member of the Household’s Contact Information 4. Adult Member of the Household’s Daytime Telephone Number 5. Adult Member of the Household’s Mobile Telephone Number (if any) 6. Adult Member of the Household’s Email Address (if any)
		Page 4, Part 4. Adult Member of the Household’s Duty of Disclosure Certification: I understand the ongoing duty to disclose information concerning any change of circumstance, as described in the Form I-600A and/or Form I-600 instructions, and I agree to notify the applicant, petitioner, and/or home study preparer and USCIS of any new information that I am required to disclose. Adult Member of the Household’s Signature Date of Signature (mm/dd/yyyy)
		Page 4, Part 5. Applicant’s or Petitioner’s Statement, Certification, Signature, and Contact Information Applicant’s or Petitioner’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. I can read and understand English, and have read and understand each and every question and instruction on this supplement, as well as my answer to each question. 1.B.  The interpreter named in Part 6. has read to me each and every question and instruction on this supplement, as well as my answer to each question, in [Fillable Field], a language in which I am fluent. I understand each and 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 [Fillable Field], who is__is not __an attorney or accredited representative, preparing this supplement for me. Applicant’s or Petitioner’s Certification I certify, under penalty of perjury under the laws of the United States of America, that the information in my supplement and any document submitted with my supplement is complete, true, and correct. 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 my records that USCIS may need to determine my suitability and eligibility 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 administration of U.S. immigration laws. Applicant’s or Petitioner’s Signature 3.Applicant’s or Petitioner's Signature Date of Signature (mm/dd/yyyy)  Applicant’s or Petitioner’s Contact Information 4. Applicant’s or Petitioner’s Daytime Telephone Number 5. Applicant’s or Petitioner’s Mobile Telephone Number (if any) 6. Applicant’s or Petitioner’s Email Address (if any)
		Page 5, [new] Part 6. Interpreter’s Name, Contact Information, Certification, and Signature If the adult member of the household and/or applicant or petitioner used an interpreter, the interpreter must provide the following information: Interpreter’s Full Name 1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name) 2. Interpreter's Business or Organization Name (if any) 3. Interpreter’s Mailing Address Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Interpreter’s Contact Information 4. Interpreter's Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification I certify that: I am fluent in English and [Fillable Field]. I have read and accurately translated to this adult member of the household and/or applicant or petitioner every question and instruction on this supplement, as well as the answer to each question in the language in which he and/or she is fluent. The adult member of the household and/or applicant or petitioner has informed me that he and/or she understands every instruction and question on the supplement, as well as his and/or her answers to each question. Interpreter’s Signature 6.   Interpreter's Signature Date of Signature (mm/dd/yyyy)  Part 7. Name, Contact Information, Statement, Certification, and Signature of the Person Preparing this Supplement, If Other Than the Adult Member of the Household, and/or Applicant or Petitioner If the adult member of the household and/or applicant or petitioner used a preparer to complete this supplement, the preparer must provide the following information: Preparer’s Full Name 1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name) 2. Preparer's Business or Organization Name (if any) 3. Preparer’s Mailing Address Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number (if any) 6. Preparer’s Email Address (if any) Preparer’s Statement 7.A. I am not an attorney or accredited representative but have prepared this supplement on behalf of the adult member of the household and/or applicant or petitioner and with the adult member of the household’s and/or applicant’s or petitioner’s consent. 7.B. I am an attorney or accredited representative and my representation of the adult member of the household and/or applicant or petitioner in this case (choose one) extends__does not extend __ beyond the preparation of this supplement. Preparer’s Certification By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this supplement on behalf of, at the request of, and with the express consent of the adult member of the household and/or applicant or petitioner. I completed this supplement based only on responses the adult member of the household and/or applicant or petitioner provided to me. After completing the supplement, I reviewed it and all of the adult member of the household’s and/or applicant’s or petitioner’s responses with the adult member of the household and/or applicant or petitioner, who agreed with each and every answer on the supplement. If the adult member of the household and/or applicant or petitionerr supplied additional information concerning a question on the supplement, I recorded it on the supplement. Preparer’s Signature 8. Preparer's Signature Date of Signature (mm/dd/yyyy)
Page 2, USCIS Privacy Act Statement	Authority: 8 CFR 204.3 authorizes USCIS to collect the information requested on this form. Purpose: This supplemental form must be completed for every adult member of the household age 18 and older who lives in the home of the prospective adoptive parent(s). The purpose of the form is to collect information on any additional adult members residing in the prospective adoptive parents' household, or who does not actually live at the same residence, but whose presence is relevant to determine suitability for adoption. Disclosure: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision or result in denial of form. Routine Uses: The information you provide on this form may be shared with other Federal, State, local, and foreign government agencies and authorized organizations following approved routine uses described in the associated published system of records notices [DHS- USCIS-005- Inter-Country Adoptions Security and DHS-USCIS-001-Alien File, Index, and National File Tracking System of Records, which can be found at www.dhs.gov/privacy]. The information may also be made available, as appropriate, for law enforcement purposes or in the interest of national security.	Page 8, AUTHORITY: The information requested on this application, petition, and/or supplement, and the associated evidence, is collected under Section 101(b)(1)(F) of the Immigration and Nationality Act (INA) [8 USC 1101], 8 CFR 204.3, and 8 CFR 204.311. PURPOSE: The purpose of Supplement 1 is to collect information on any adult members of the household. This Supplement must be completed for any individual, other than you and your spouse (if married), who has the same principal residence as you and is 18 years of age or older on or before the date that Form I-600A or Form I-600 is filed. Residence is defined as the place of general abode or a person's principal, actual dwelling place in fact, without regard to intent. USCIS reserves the right to request information on any household member who has not yet reached his or her 18th birthday before the date when Form I-600A or Form I-600 is filed, or who does not actually live at the same residence, but whose presence in the residence is relevant to the issue of your and your spouse's suitability to adopt. DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any requested evidence, may delay a final decision or result in denial of your application or petition. ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local, and foreign government agencies and authorized organizations following approved routine uses described in the associated published system of records notices [DHS/USCIS-005 - Inter-Country Adoptions Security and DHS-USCIS-001 - Alien File, Index, and National File Tracking System of Records, which can be found at www.dhs.gov/privacy]. The information may also be shared, as appropriate, for law enforcement purposes or in the interest of national security.

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