Form I-600a - Application For Advance Processing Of An Orphan Petition Page 3
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3BLOCK II - General Information (Continued)
18. Do you plan to adopt more than one child?
No
Yes
If "Yes," how many children do you plan to adopt?
BLOCK III - Accommodations for Individuals With Disabilities and Impairments (Read the information in the
instructions before completing this section.)
19. I am requesting an accommodation:
1. Because of my disability(ies) and/or impairment(s).
Yes
No
Yes
No
2. For my spouse because of his or her disability(ies) and/or impairment(s).
No
Yes
3. For my household member because of his or her disability(ies) and/or impairment(s).
If you answered "Yes," check any applicable box. Provide information on the disability(ies) and/or impairment(s) for each
person:
Deaf or hard of hearing and request the following accommodation(s) (if requesting a sign-language interpreter, indicate
which language (e.g., American Sign Language)):
Blind or sight-impaired and request the following accommodation(s):
Other type of disability(ies) and/or impairment(s) (describe the nature of the disability(ies) and/or impairment(s) and
accommodation(s) being requested):
Certification of Prospective Adoptive Parent
Certification of Married Prospective Adoptive Parent
Spouse
I certify, under penalty of perjury under the laws of the United States
of America, that the foregoing is true and correct and that I will care
I certify, under penalty of perjury under the laws of the United States
for an orphan/orphans properly if admitted to the United States.
of America, that the foregoing is true and correct and that my spouse
and I will care for an orphan/orphans properly if admitted to the
United States.
(Signature of Prospective Adoptive Parent)
(Signature of Prospective Adoptive Parent Spouse)
Executed on (Date)
Executed on (Date)
Signature of Person Preparing Form, If Other Than Petitioner
I declare that this document was prepared by me at the request of the petitioner and is based entirely on information of which I have knowledge.
(Signature)
Executed on (Date)
Street Address and Room or Suite No./City/State/Zip Code
Form I-600A (Rev. 01/12/11) Y Page 3
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