Form I-800a - Application For Determination Of Suitability To Adopt A Child From A Convention Country

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Form I-800A, Application for Determination of Suitability
Department of Homeland Security
U.S. Citizenship and Immigration Services
to Adopt a Child from a Convention Country
START HERE - Type or Print (Use black ink)
For USCIS Use Only
Receipt
Part 1.
Information About You
(Person filing this application)
Returned
1. Provide the following information about yourself:
Date
Family Name (Last Name)
Given Name (First Name)
Middle Name
Date
Resubmitted
Other Names Used (including maiden name if appropriate)
Date
USCIS Account #
U.S. Social Security # (if any)
Date
Reloc Sent
Date of Birth (mm/dd/yyyy)
Place of Birth (City/Town, State/Province, Country)
Date
Home Address - Street Number and Name
Apt. #
Date
Reloc Rec'd
City
State or Province
Date
Zip/Postal Code
Country
Date
This application was filed by:
Mailing Address (if different from home address)
Apt. #
A Married Applicant
An Unmarried Applicant
C/O (in care of)
This application is approved for a
Convention adoptee from:
City
State or Province
(Name of Convention Country)
Zip/Postal Code
Country
Period of approval valid until:
(Date)
2. I intend to adopt a child habitually residing in the following Convention country:
Action Block
Warning: If you are seeking to adopt a child who is habitually residing in a country
other than a Convention country, STOP. You cannot file this application. See Pages
1 to 2 of the Form I-800A instructions for additional filing information.
3. I am a habitual resident of the United States as:
A person who is domiciled in the United States.
A person who is domiciled in the United States, even if temporarily living outside
the United States.
To Be Completed By
A person who will establish a domicile in the United States on or before the date
Attorney or Representative, if any.
of the child's admission to the United States for permanent residence as a
Fill in box if G-28 is attached to
Convention adoptee.
represent the applicant.
A person domiciled outside the United States who will bring the child to the
ATTY State License #
United States after adoption and before the child's 18th birthday for naturalization
as a U.S. citizen.
Form I-800A (Rev. 03/10/17) N

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