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?
Remarks:
START HERE - Type or Print (Use black ink)
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)
Mailing Address
City State or Province CountryZip/Postal Code
Apt. #
Yes
No
Yes No
Yes No
Yes No
Form I-800A, Supplement 1 (Rev. 03/10/17 N) Page 2
E-Mail Address
(if any)
I declare that I completed Form I-800A, Supplement 1, Part 1 and it is based on all information of which I have knowledge. I have
not knowingly withheld any material information that would affect the outcome of this application.
Adult Member of the Household's Signature
Pursuant to the Privacy Act, 5 U.S.C. 552a, I also authorize USCIS to disclose information about me which may appear in any system
of records maintained by the U.S. Department of Homeland Security, or which USCIS may obtain as a result of the collection of my
biometrics information, to the applicant(s) who have filed Form I-800A, or to the applicant's adoption service provider, in order to
assist USCIS in adjudicating Form I-800A.
1. Each answer I have given to each question on Form I-800A and attached supplement(s) 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:
Certification of the adult member of the household:
2. I understand the ongoing duty to disclose any change in circumstance, as described on Page 7 of the instructions to Form
I-800A. I agree to notify the applicant of any new information that I am required to disclose.
Other Names Used (including maiden name if appropriate)
Date (mm/dd/yyyy)
Your Signature (Applicant)
Applicant Family Name (Last Name) Applicant Middle NameApplicant Given Name (First Name)
Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)
USCIS Account # (if any)
U.S. Social Security # (if any) A # (if any)
Date (mm/dd/yyyy)
Daytime Phone Number
(with area code)
Part 2. Signature of You, the Prospective Adoptive Parent (Applicant) and Signature and Certification of the Adult Member
of the Household (Read the information on penalties on Page 10 of the instructions before completing this section.)