Form I-800A, Supplement 1, Listing
of Adult Member of the Household
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-800A, Supplement 1 (Rev. 03/10/17 N)
Part 1. Information About an Adult Member of the Household. (You must
complete Form I-800A, Supplement 1, for each adult member of the household
age 18 and older. However, if you are married, you do not need to complete one
for your spouse.)
Notice to the Adult Member of the Household: By signing Form I-800A, Supplement 1,
you agree that USCIS may disclose to the applicant or the applicant's adoption service
provider information that USCIS may obtain about you that is relevant to the adjudication
of the applicant's Form I-800A, even if the Privacy Act, 5 U.S.C. 552a, might otherwise
prevent disclosure of the information.
c. 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?
Each of the above questions must be answered. See "Duty of Disclosure" on Page 7 of the instructions to Form I-800A concerning
your ongoing duty to disclose information in answer to these questions. If the answer is "Yes" to any of the 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; 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.
b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?
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For USCIS Use Only
1. Provide the following information about the adult member of the household:
2. Has the adult member of the household, whether in or outside the United States:
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?
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?
Other Names Used (including maiden name if appropriate)
Family Name (Last Name)
A # (if any) U.S. Social Security # (if any)
Given Name (First Name) Middle Name
Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)
C/O (in care of)
City State or Province CountryZip/Postal Code