Form I-800a - Supplement 1 - Application For Determination Of Suitability To Adopt A Child From A Convention Country Page 2

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Part 2. Signature of You, the Prospective Adoptive Parent (Applicant) and Signature and Certification of the Adult Member
of the Household (Read the information on penalties on Page 10 of the instructions before completing this section.)
I declare that I completed Form I-800A, Supplement 1, Part 1 and it is based on all information of which I have knowledge. I have
not knowingly withheld any material information that would affect the outcome of this application.
Your Signature (Applicant)
Date (mm/dd/yyyy)
Applicant Family Name (Last Name)
Applicant Given Name (First Name)
Applicant Middle Name
Other Names Used (including maiden name if appropriate)
Date of Birth (mm/dd/yyyy)
Place of Birth (City/Town, State/Province, Country)
USCIS Account # (if any)
U.S. Social Security # (if any)
A # (if any)
Certification of the adult member of the household:
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 any change in circumstance, as described on Page 7 of the instructions to Form
I-800A. I agree to notify the applicant of any new information that I am required to disclose.
Pursuant to the Privacy Act, 5 U.S.C. 552a, I also authorize USCIS to disclose information about me which may appear in any system
of records maintained by the U.S. Department of Homeland Security, or which USCIS may obtain as a result of the collection of my
biometrics information, to the applicant(s) who have filed Form I-800A, or to the applicant's adoption service provider, in order to
assist USCIS in adjudicating Form I-800A.
Adult Member of the Household's Signature
Date (mm/dd/yyyy)
Daytime Phone Number
E-Mail Address
(with area code)
(if any)
Form I-800A, Supplement 1 (Rev. 03/10/17 N) Page 2

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