Fillable Form I-800a - Supplement 2 - Consent To Disclose Information printable pdf download

Form I-800A, Supplement 2,

Department of Homeland Security

U.S. Citizenship and Immigration Services

Consent to Disclose Information

START HERE - Type or Print (Use black ink)

For USCIS Use Only

Remarks:

NOTICE

Information that USCIS may have concerning your Form I-800A, Application for

Determination of Suitability to Adopt a Child From a Convention Country, is protected

from disclosure under the Privacy Act, 5 U.S.C. 552a. USCIS generally may not disclose

this information to your adoption service provider without your consent. If you want

USCIS to be able to disclose this information to your adoption service provider, you may

give this consent by signing Form I-800A, Supplement 2. You do not need to sign Form

I-800A, Supplement 2, in order to file Form I-800A

Provide the below information about your primary adoption service provider who is the 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. If a primary adoption service provider has not yet

been identified, provide the name and address of the adoption service provider who is the accredited agency, as defined in 22 CFR

Part 96.2, who either prepared and approved your home study, or reviewed and approved your home study, or the Public Domestic

Authority who both prepared and approved your home study.

Pursuant to the Privacy Act, 5 U.S.C. 552a, and 8 CFR Part 204.302, and in order to assist USCIS in the adjudication of Form

I-800A, I (we), the undersigned applicant(s) filing Form I-800A, consent to the disclosure of any record pertaining to me (us)

which appears 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 (our) biometrics information, to the following adoption service provider:

Name of Adoption Service Provider

Point of Contact (contact person within the organization)

Street Number and Name

Suite #

Country

City

State or Province

Zip/Postal Code

Daytime Phone # (with area/country code)

Fax Number (if any)

E-Mail Address (if any)

I (We) understand that, by signing this supplement, I am (we are) authorizing USCIS to provide the adoption service provider

noted above with copies of notices sent to me (us) about this case, and also to discuss my (our) case with that adoption service

provider.

I (We) also understand that an adoption service provider can only provide adoption services, and cannot act as my (our)

representative before USCIS with respect to my (our) case unless the adoption service provider is authorized to do so under 8 CFR

part 292. I (We) also understand that the adoption service provider cannot provide any other legal services, unless the adoption

service provider is authorized to do so under the law governing the provision of legal services in the country or State in which the

legal service is provided.

Your Signature and Printed Name

Date (mm/dd/yyyy)

USCIS Account # (if any)

Signature of Spouse and Printed Name (if you are married)

Date (mm/dd/yyyy)

USCIS Account # (if any)

Form I-800A, Supplement 2 (Rev. 03/10/17 N)

Form I-800a - Supplement 2 - Consent To Disclose Information

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