Form I-600A/I-600 Supplement 1 12/23/16 N Page 2 of 7
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.
Alien Registration Number (A-Number) (if any)11.
State or Province of Birth9. Country of Birth10.
Duty of Disclosure
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?
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?
Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?B.
Has the adult member of the household EVER, whether in or outside the United States:12.
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?
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)
Alien Registration Number (A-Number) (if any)6.
2. Date of Birth (mm/dd/yyyy) City/Town/Village of Birth 3.
State or Province of Birth4. Country of Birth5.
Part 1. Information About an Adult Member of the Household (continued)