Fillable I-800asup3 (USCIS)

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I-800asup3 (USCIS)

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form I-800A, Supplement 3, Request
for Action on Approved Form I-800A
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-800A, Supplement 3 (Rev. 03/10/17 N)
Part 1. Information About You (Person who filed a previously approved Form
I-800A, Application for Determination of Suitability to Adopt a Child from a
Convention Country)
2. I am requesting:
a.
Fill in box if G-28 is attached to
represent the applicant.
Attorney or Representative, if any.
START HERE - Type or Print (Use black ink)
Returned
Date
Date
Date
Date
Date
Date
Date
Resubmitted
Reloc Sent
Reloc Rec'd
Receipt
For USCIS Use Only
ATTY State License #
To Be Completed By
1.
Action Block
Continued on next page.
Extension granted to:
New Convention country:
Other change.
(Name of Country)
(Date)
Duplicate approval notice.
Other Names Used (including maiden name if appropriate)
Family Name (Last Name) Given Name (First Name) Middle Name
State or Province
Home Address - Street Number and Name
City
Zip/Postal Code Country
Apt. #
Place of Birth (City/Town, State/Province, Country)Date of Birth (mm/dd/yyyy)
Country
E-Mail Address (if any)
State or Province
Mailing Address (if different from home address)
City
Zip/Postal Code
Apt. #
C/O (in care of)
Date of Approval
(mm/dd/yyyy)
Date Approval Expires
(mm/dd/yyyy)
USCIS
Receipt #
Location of USCIS Office Where Filed USCIS Account # (if known)
Part 2. Action Requested on Your Previously Approved Form I-800A
Daytime Phone # (with area/country code)
b.
A SECOND or SUBSEQUENT extension of the approval of my Form I-800A,
and I have not yet submitted Form I-800 on behalf of a specific child. If any
changes have occurred, I will indicate such change in Item 3 on the following
page. (An application fee and biometrics fee are required and an updated/
amended home study must be submitted.)
My FIRST extension of the approval of my Form I-800A, and I have not yet
submitted Form I-800 on behalf of a specific child. If any changes have
occurred, I will indicate such change in Item 3 on the following page. (No fee
is required and an updated/amended home study must be submitted.)
Form I-800A, Supplement 3 (Rev. 03/10/17 N) Page 2
3. Information on changes that have occurred since Form I-800A with supplements (if any) was approved or extended. Check all
boxes that apply. (NOTE: All changes must be fully explained and evaluated in the required updated home study.)
NOTE: For detailed fee information, see "What is the Filing Fee?" on Pages 8 to 10 of the Form I-800A instructions.
Part 2. Action Requested on Your Previously Approved Form I-800A (Continued)
There have been no changes.
History of arrest.
History of sexual abuse.
History of family violence.
History of substance abuse.
History of child abuse or neglect.
Change in Convention country.
Financial status.
Residence.
Marital status. STOP. Do not file this form. You must file a new Form I-800A.
Name of the new Convention country
A new approval notice based on changes in circumstances since my From I-800A was approved, and I am not requesting an
extension, and:
c.
d.
e.
f.
1.
I have not yet submitted Form I-800 on behalf of a specific child; or
2.
I was directed to file Form I-800A, Supplement 3, by USCIS or U.S. Department of State after filing Form I-800 in
behalf of a specific child.
Complete Item 3 below. (The fee must be paid and an updated/amended home study must be submitted.)
A duplicate approval notice. I am not requesting an extension and there has been no change in circumstances since my
Form I-800A was approved. (The fee must be paid.)
A SECOND or SUBSEQUENT change in a Convention country, that was not previously included in my most recent home
study recommendation and my Form I-800A or Form I-800A, Supplement 3 approval notice. I have not yet submitted
Form I-800 on behalf of a specific child. No extension requested. (The fee must be paid and an amended home study
recommending the adoption in the new Convention country must accompany this application.) NOTE: If requesting both
an extension and a change of Convention country, check Item 2, a, or 2, b, and also indicate the change in Item 3 below.
A FIRST TIME change in a Convention country, that was not previously included in my home study recommendation and
my Form I-800A approval notice. I have not yet submitted Form I-800 on behalf of a specific child. No extension
requested. (No fee is required but an amended home study recommending the adoption in the new Convention country must
accompany this application.) NOTE: If requesting both an extension and a change of Convention country, check Item 2,
a, or 2, b, and also indicate the change in Item 3 below.
Form I-800A, Supplement 3 (Rev. 03/10/17 N) Page 3
2. I understand the ongoing duty to disclose information concerning my suitability as an adoptive parent, as described on Page 7
of the instructions to Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.
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:
Your certification:
Change in the number of children or characteristics (such as age, gender, or special needs) of child(ren) you intend to
adopt. (If you add to the number of children you intend to adopt and the children are not already siblings before the
proposed adoption, an additional filing fee will be required when you file Form I-800 for the second or subsequent child. For
more detailed fee information, see "What is the Filing Fee?" of Form I-800A instructions.)
Part 2. Action Requested on Your Previously Approved Form I-800A (Continued)
Change in number and/or identity of adult members of the household. (If you check this box, Form I-800A, Supplement
1, should be completed and submitted for each new adult member of the household with the required biometrics fee.)
Change in number and/or identity of children in the household. (Use a separate sheet of paper for additional children.)
Name
(First/Middle/Last)
Date of Birth
(mm/dd/yyyy)
Country
of Birth
A #
(if applicable)
Relationship to You
(if any)
Other. (If you checked this box, provide additional information about the change(s). If you need more space to complete,
use a separate sheet of paper. Write your name and USCIS Account Number, if known, at the top of each sheet of paper and
indicate the part and number of the item to which the answer refers.)
Part 3. Certification and Signature of You, the Prospective Adoptive Parent(s) (Read the information on penalties in the
instructions before completing this section.)
Your Signature
Date (mm/dd/yyyy)
Form I-800A, Supplement 3 (Rev. 03/10/17 N) Page 4
Fax Number
(with area code)
Attorney or Representative Only:
In the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
I declare that I prepared this application at the request of the above person(s), and it is based on all information provided to me by the
person(s). I have not knowingly withheld any material information that would affect the outcome of this application.
NOTICE: If you want to give consent for USCIS to disclose information about your case to your adoption service provider, you
should complete Form I-800A, Supplement 2, Consent to Disclose Information. You are not required to give this consent in order to
file Form I-800A.
ALSO: If you had assistance in filling out this application, the person preparing the form must complete Part 4. Only an individual
or organization provided for in 8 CFR Part 292 may represent you before USCIS and provide legal services in relation to this
immigration proceeding.
If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible
for the benefit sought and this application will be denied.
I certify, under penalty of perjury under the laws of the United States, that:
2. I understand the ongoing duty to disclose information concerning my suitability as an adoptive parent, as described on Page 7
of the instructions to Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.
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
Certification of your spouse (if you are married):
Part 3. Certification and Signature of You, the Prospective Adoptive Parent(s) (Continued)
Date (mm/dd/yyyy)
Signature of Spouse
Part 4. Signature of Person Preparing Form if Other Than Above (Sign below)
Preparer's Firm Name (if applicable)
Yes No
Preparer's Address
Date (mm/dd/yyyy)
Preparer's Signature
Preparer's Printed Name
E-mail Address
(if any)
Daytime Phone Number
(with area code)
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Completed 24 July 2020

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