Form I-800 03/10/17 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.
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
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.
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.)
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
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
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.
If the legal custodians are both the child’s birth parents, the factual basis for concluding that they are incapable of providing
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
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: