Form I-800a - Application For Determination Of Suitability To Adopt A Child From A Convention Country Page 8
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9Part 3.
General Information
(Continued)
7. Other than a spouse, is there any person 18 years of age or older residing with you?
Yes
No
If "Yes," you must complete Form I-800A Supplement 1, Listing of Adult Member of
the Household, for each person.
8. List all your children under 18 years of age. Also include any child under 18 years of age residing in your household even if you
are not the parent of such child.
Name
Date of Birth
Country
A #
Relationship to You
(First/Middle/Last)
(mm/dd/yyyy)
of Birth
(if applicable)
(if any)
Part 4. Certification and Signature of You, the Prospective Adoptive Parent(s) (Read the information on penalties in the
instructions before completing this section.)
Your certification:
I certify, under penalty of perjury under the laws of the United States, that:
1. Each answer I have given to each question on Form I-800A and attached supplement(s) is true and correct to the best of my
knowledge, information, and belief; and
2. I understand the ongoing duty to disclose information concerning my suitability as an adoptive parent, as described on Page 7
of the instructions to Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.
Your Signature
Date (mm/dd/yyyy)
Certification of your spouse (if you are married):
I certify, under penalty of perjury under the laws of the United States, that:
1. Each answer I have given to each question on Form I-800A and attached supplement(s) is true and correct to the best of my
knowledge, information, and belief; and
2. I understand the ongoing duty to disclose information concerning my suitability as an adoptive parent, as described on Page 7
of the instructions to Form I-800A, and I agree to notify the home study preparer and USCIS of any new information that I am
required to disclose.
Signature of Spouse
Date (mm/dd/yyyy)
If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible
for the benefit sought and this application will be denied.
Form I-800A (Rev. 03/10/17) N Page 8
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