Form I-800a - Application For Determination Of Suitability To Adopt A Child From A Convention Country Page 3
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9Part 1.
Information About You
(Continued)
c. Information on all previous marriages, if applicable. Begin with the most recent termination.
1. Number of Previous Marriages
(Do not count current marriage)
2. Provide the following information on each terminated marriage (if applicable):
a. Date Marriage Ended
Name of
How Marriage
(mm/dd/yyyy)
Prior Spouse
Ended
Divorce
Death
Other
b. Date Marriage Ended
Name of
How Marriage
(mm/dd/yyyy)
Prior Spouse
Ended
Divorce
Death
Other
NOTE: 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.
9. My contact information is (all phone numbers must include area code and country code, if applicable):
Daytime Phone #
Home Phone #
E-Mail Address
(with area/country code)
(if different from daytime #)
(if any)
10. 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?
b. Been the beneficiary of a pardon, amnesty, rehabilitation decree, other act of clemency, or similar
Yes
No
action?
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?
d. At any time been the subject of any investigation by any child welfare agency, court, or other official
Yes
No
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?
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 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 would like considered in light of this history
on a separate sheet of paper.
Form I-800A (Rev. 03/10/17) N Page 3
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