Form I-600 - Petition To Classify Orphan As An Immediate Relative Page 4
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14Part 1. Information About You (Petitioner) (continued)
22.
Have you ever previously filed Form I-600, Form I-600A, Application for Advance Processing of an
Yes
No
Orphan Petition, Form I-800A, Application for Determination of Suitability to Adopt a Child From a
Convention Country, or Form I-800, Petition to Classify Convention Adoptee as an Immediate Relative?
If "Yes," provide the following:
A.
Type of Petition/Application Filed
B. Result- Check the box that best describes the action taken by USCIS and/or U.S. Department of State on your petition and/or
application.
►
Approved - Approval Date
(mm/dd/yyyy)
(mm/dd/yyyy) ►
Denied - Denial Date
NOTE: A copy of the denial notice must accompany this petition.
Other - Explain
C.
A detailed description of any previous Form I-600 or Form I-800 filing that resulted in a disruption prior to finalization of the
adoption or that resulted in a completed adoption that was later dissolved either in the United States or abroad.
NOTE: If you need extra space to complete this question, attach a separate sheet of paper; type or print your A-Number (if any)
at the top of each sheet; include the Page Number, Part Number, and Item Number to which your answer refers; and sign and
date each sheet.
Duty of Disclosure
You and your spouse (if married) must answer the following questions. See the Duty of Disclosure section in the Form I-600
instructions concerning your ongoing duty to disclose information in response to these questions. If you or your spouse answer "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 you and/or your spouse (if married) 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 your spouse (if married) would like
considered in light of this history on a separate sheet of paper; type or print your name and A-Number (if any) at the top of each sheet;
indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet.
23.
Have you EVER, whether in or outside the United States:
A.
Been arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or violating any
Yes
No
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, even if the
record of the arrest, conviction, or other adverse criminal history was expunged, sealed, pardoned, or
the subject of any other amelioration?
B.
Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action?
Yes
No
C. Received a suspended sentence, been placed on probation or parole, or in an alternative sentencing or
Yes
No
rehabilitation program, such as diversion, deferred prosecution, deferred or withheld adjudication, or
expungement of a criminal charge?
Form I-600 12/23/16 N
Page 4 of 14
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