Form I-800a - Application For Determination Of Suitability To Adopt A Child From A Convention Country Page 9

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Part 4. Certification and Signature of You, the Prospective Adoptive Parent(s)
(Continued)
NOTICE: If you want to give consent for USCIS to disclose information about your case to your adoption service provider, you
should complete Form I-800A, Supplement 2, Consent to Disclose Information. You are not required to give this consent in order to
file Form I-800A.
ALSO: If you had assistance in filling out this application, the person preparing the form must complete Part 5. Only an individual
or organization provided for in 8 CFR Part 292 may represent you before USCIS and provide legal services in relation to this
immigration proceeding.
Part 5. Signature of Person Preparing Form if Other Than Above (Sign below)
I declare that I prepared this application at the request of the above person(s), and it is based on all information provided to me by the
person(s). I have not knowingly withheld any material information that would affect the outcome of this application.
Attorney or Representative Only:
n the event of a Request for Evidence (RFE), may USCIS contact you by fax or e-mail?
I
Yes
No
Preparer's Signature
Date (mm/dd/yyyy)
Preparer's Printed Name
Preparer's Firm Name (if applicable)
Preparer's Address
Daytime Phone Number
Fax Number
E-Mail Address
(with area code)
(with area code)
(if any)
Form I-800A (Rev. 03/10/17) N Page 9

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