Form I-800a - Application For Determination Of Suitability To Adopt A Child From A Convention Country Page 6
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9Part 2.
Information About Your Spouse
(Continued)
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 by your spouse 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 would like considered in light
of this history on a separate sheet of paper.
Part 3.
General Information
1. The home study:
Is attached to this application.
Is not attached to this application because of State requirements necessitating review and documentation. The appropriate
State authority has indicated that it will submit the home study directly to USCIS. (Do not submit your Form I-800A to
USCIS until the State authority is ready to send the home study to USCIS.)
2. Name and Address of Adoption Service Provider. Provide the name and address of either (Check one):
a.
The adoption service provider that is responsible for your home study (either the accredited agency or temporarily accredited
agency, as defined in 22 CFR 96.2, that prepared and approved your home study or reviewed and approved your home study
after it was prepared by another authorized home study preparer, or the public domestic authority, as defined in 22 CFR
96.2, that both prepared and approved your home study); or
b.
The primary adoption service provider who is responsible in your case, if you have already identified a primary adoption
service provider. (A primary adoption service provider is an 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 in a Convention adoption case.)
Name of Adoption Service Provider
Point of Contact (contact person within the organization)
Daytime Phone # (with area/country code)
Street Number and Name
Suite #
Country
City
State or Province
Zip/Postal Code
Form I-800A (Rev. 03/10/17) N Page 6
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