Form I-800, Supplement 1,
Consent to Disclose Information
Department of Homeland Security
U.S. Citizenship and Immigration Services
Information that USCIS may have concerning your Form I-800, Petition to Classify
Convention Adoptee as an Immediate Relative, is protected from disclosure under the
Privacy Act, 5 U.S.C. 552a. USCIS generally may not disclose this information to your
adoption service provider without your consent. If you want USCIS to be able to disclose
this information to your primary adoption service provider, you may give this consent by
signing Form I-800, Supplement 1. You do not need to sign Form I-800, Supplement 1,
in order to file Form I-800. Note: Your primary adoption service provider is the
accredited or temporarily accredited agency, or approved person who is responsible under
22 CFR Part 96.14 for the six adoption services defined in 22 CFR Part 96.2, and for
supervising and being responsible for supervised providers where used.
I (We) also understand that an adoption service provider can only provide adoption services, and cannot act as my (our)
representative before USCIS with respect to my (our) case unless the adoption service provider is authorized to do so under 8 CFR
Part 292. I (We) also understand that the adoption service provider cannot provide any other legal services, unless the adoption
service provider is authorized to do so under the law governing the provision of legal services in the country or State in which the
legal service is provided.
Remarks:
NOTICE
START HERE - Type or Print (Use black ink)
For USCIS Use Only
Pursuant to the Privacy Act, 5 U.S.C. 552a, and 8 CFR 204.302, and in order to assist USCIS in the adjudication of Form I-800, I
(we), the undersigned petitioner(s) filing Form I-800, consent to the disclosure of any record pertaining to me (us) which appears
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 (our) biometrics information to the following primary adoption service provider:
I (We) understand that, by signing this supplement, I am (we are) authorizing USCIS to provide the primary adoption service
provider noted above with copies of notices sent to me (us) about this case, and also to discuss all aspects of my (our) case,
including the prior Form I-800A proceeding as well as this Form I-800 proceeding.
SPECIFY whether you are withdrawing the consent to disclosure that you gave on a prior Form I-800A, Supplement 2, Consent to
Disclose Information, or Form I-800, Supplement 1, Consent to Disclose Information:
Your Signature and Printed Name
Street Number and Name
Name of Primary Adoption Service Provider
Point of Contact (contact person within the organization)
City State or Province Country
USCIS Account # (if any)
E-Mail Address (if any)
Zip/Postal Code
Suite #
Daytime Phone # (with area/country code) Fax Number (if any)
Date (mm/dd/yyyy)
Signature of Spouse and Printed Name (if you are married)
USCIS Account # (if any)
Date (mm/dd/yyyy)
Yes, I am (we are) withdrawing all prior consents to disclose.
No, USCIS may continue to disclose information to any adoption service provider included on any prior Form I-800A,
Supplement 2, or Form I-800, Supplement 1.
Form I-800, Supplement 1 03/10/17 N
