Fillable Form I-800A, Supplement 3.: Adoptee As An Immediate (Visa Pro)

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Form I-800A, Supplement 3.: Adoptee As An Immediate (Visa Pro)

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Form I-800, Petition to Classify Convention
Adoptee as an Immediate Relative
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-800 12/23/16 N
2. Is the daytime phone number the same as the one provided on
Form I-800A?
START HERE - Type or Print (Use black ink)
Other Names Used (including maiden name if appropriate)
1. Provide the following information about yourself:
NOTICE
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.
Part 1. Information About You (Person filing this petition)
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 State or Province
Zip/Postal Code Country
E-Mail Address
(if any)
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)
Contact Information:
Daytime Phone #
(with area/country code)
3. Is the e-mail address (if any) the same as the one provided on
Form I-800A?
Yes No
Yes No
Returned
Date
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
For Official Use Only
ATTY State License #
To Be Completed By
Attorney or Representative, if any.
Check if G-28 is attached.
1. The petition is provisionally approved
for a Convention Adoptee who will be:
Adopted
abroad.
2. The child will seek:
IV.
Adjustment of Status under Sec. 245.
Provisional Action Block:
Final Action Block:
Officer Signature Date
Coming to the U.S. for
adoption. Preadoption
requirements met.
Child's legal name after adoption:
NIV, so as to apply for
naturalization under Sec. 322
after lawful admission.
3. The petitioner is:
Married Unmarried
Form I-800 12/23/16 N Page 2
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.
4. If you are married, complete "a" and "b" below.
Part 1. Information About You (Continued)
Part 2. Processing Information
Family Name (Last Name) Given Name (First Name) Middle Name
USCIS
Account #
U.S. Social Security #
(if any)
Date of Birth
(mm/dd/yyyy)
Place of Birth
(City/Town, State/Province, Country)
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.
b. Does your spouse reside with you?
Home Address - Street Number and Name
City State or Province CountryZip/Postal Code
Apt. #
Mailing Address (if different from home address)
C/O (in care of)
City State or Province CountryZip/Postal Code
Apt. #
Contact Information:
Daytime Phone #
(with area/country code)
E-Mail Address
(if any)
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.
1. Provide the following information on your previously approved Form I-800A.
2. Check "a," "b," or "c." (If none of the below options apply, STOP. You cannot file this petition.)
a.
Date of Approval
(mm/dd/yyyy):
Date Approval/Extension Expires
(mm/dd/yyyy)
USCIS
Receipt #
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.
Yes No
a. Provide the following information about your spouse:
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.
b.
Form I-800 12/23/16 N Page 3
Part 2. Processing Information (Continued)
Part 3. Information About the Beneficiary (Convention adoptee)
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.
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.
(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.)
Foreign CountryCity in Foreign Country
Yes No
Yes No
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.
5. If you are filing more than one Form I-800, are the children already siblings prior to the proposed
adoption?
1. Give the following information about the child's current name.
Middle Name
Family Name (Last Name) Given Name (First Name)
2. Give the following information about the child's name at the time of birth, if known.
Middle Name
Family Name (Last Name)
Given Name (First Name)
3. Give any other name that the child is or was known as:
Middle NameFamily Name (Last Name) Given Name (First Name)
Gender
4. Give the following information about the child's birth.
Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)
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?
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.
c.
Form I-800 12/23/16 N Page 4
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.
7. The child’s legal custodian is (Check only one box):
Part 3. Information About the Beneficiary (Continued)
8. The child will reside with me (Choose one):
a.
b.
City State Zip Code
Street Number and Name
City State or Province Zip/Postal Code Country
Street Number and Name
9. Are you submitting with Form I-800:
If "Yes," to either 9, a, or 9, b, go to Question 12.
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
Yes No
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).
In the United States at the following address:
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)).
Form I-800 12/23/16 N Page 5
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.)
Part 3. Information About the Beneficiary (Continued)
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.
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.)
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
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:
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.
a.
If the legal custodians are both the child’s birth parents, the factual basis for concluding that they are incapable of providing
proper care.
b.
c.
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.
d.
If the legal custodian is the child’s surviving birth parent, proof of the other birth parent’s death.
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:
a.
b.
Form I-800 12/23/16 N Page 6
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:
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.
Intend to adopt the child in the Convention country. If you check this box, go to Item 22.
a.
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.
b.
Form I-800 12/23/16 N Page 7
27. Select which of the following you are filing with your Form I-800:
Part 3. Information About the Beneficiary (Continued)
The above named primary adoption service provider is one of the following:
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
City/Town CountryState or Province
State Zip Code
E-Mail Address
(if any)
Phone Number
(with area code)
Fax Number
(with area code)
a. An accredited or temporarily accredited agency in the United States.
Yes No
b. An approved person in the United States.
Yes No
Not applicable
(Child will be
adopted outside
United States)
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
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
Zip/Postal CodePhone Number (with area/country 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:
b. A properly completed Form I-864W, Intending Immigrant's Affidavit of Support Exemption.
a. A properly completed Form I-864, Affidavit of Support Under Section 213A of the Act; OR
Yes No
Yes No
Form I-800 12/23/16 N Page 8
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.
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)
Anticipated Date
of Payment
(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.
Form I-800 12/23/16 N Page 9
Fax Number
(with area code)
Part 5. Certification and Signature of You, the Prospective Adoptive Parent(s) (Read the information on penalties in the
instructions before completing this section.)
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 certification:
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
I certify, under penalty of perjury under the laws of the United States, that:
Your Signature
Date (mm/dd/yyyy)
Signature of Spouse
Date (mm/dd/yyyy)
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.
I certify, under penalty of perjury under the laws of the United States, that:
Certification of your spouse (if you are married):
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.
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.
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 Firm Name (if applicable)
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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Form I-800A, Supplement 3.: Adoptee As An Immediate (Visa Pro)

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Completed 29 July 2020

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