Form I-600A 12/23/16 N Page 5 of 12
Part 1. Information About You (Applicant) (continued)
No
Yes
No
Yes
NoYes
No
Yes
No
Yes
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?
D.
24. Has your spouse 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?
A.
Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?
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?
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?
C.
B.
Part 2. Information About Your Home Study Preparer and/or Adoption Service Provider
Your home study:1.
IS NOT attached to this Form I-600A because of state requirements necessitating review and documentation. The
appropriate state authority has indicated that it will submit the home study directly to U.S. Citizenship and Immigration
Services (USCIS). (Do not submit your Form I-600A to USCIS until the state authority is ready to send your home
study to USCIS.)
IS attached to this Form I-600A.A.
B.
Will be submitted within one year from the date of this Form I-600A filing. (If your home study is not received within
one year, your Form I-600A application will be denied under 8 CFR 204.3(c)(2) and (h)(5).)
C.
Select one of the following options for which you will provide a name, address, and contact information in Item Number 3.:
A.
2.
The adoption service provider that is responsible for your home study (i.e., the accredited agency as defined in 22 CFR 96.2,
that prepared 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 prepared 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 agency or approved person who is responsible
under 22 CFR 96.14 for ensuring the six adoption services defined in 22 CFR 96.2 are provided, supervising and being
responsible for supervised providers where used, and developing and implementing a service plan in accordance with 22
CFR 96.44.)
3. Provide the name and contact information of your adoption service provider.
Name of Adoption Service ProviderA.
B. Point of Contact Within the Organization
Family Name (Last Name)
Given Name (First Name)