Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 1 of 9

Supplement 1, 

Listing of Adult Member of the Household 

Department of Homeland Security 

U.S. Citizenship and Immigration Services 

USCIS 

Form I-600A/I-600 

Supplement 1 

OMB No. 1615-0028 

Expires 02/28/2026

Part 1. Information About an Adult Member of the Household

Provide the following information about the Adult Member of the Household.

1. 

U.S. Mailing Address (if any) 

2.

3.

Family Name (Last Name)

Family Name (Last Name) Given Name (First Name) Middle Name (if applicable)

Given Name (First Name) Middle Name (if applicable)

Other Names Used by the Adult Member of the Household (if any)

City or Town State ZIP Code

Street Number and Name Apt. Ste. Flr. Number

In Care Of Name (if any)

Number

U.S. Physical Address (if any)

Is the current U.S. mailing address the same as the adult member of the household's U.S. physical address?

Street Number and Name

City or Town State ZIP Code

Apt. Ste. Flr.

If you answered "No," provide the U.S. physical address in Item Number 5. or an address abroad in Item Number 6., as 

appropriate.

4.

5.

Yes No

 START HERE - Type or print in black ink. You, the applicant or petitioner, must complete Form I-600A/Form I-600, 

Supplement 1, for EACH adult member of your household 18 years of age or older. Do not complete this separate Supplement 1 for 

yourself or your spouse (if married).

►

Address Abroad (if any)

Street Number and Name Number

City or Town State

Apt. Ste. Flr.

Province Postal Code Country

6. 

Provide all other names the adult member of the household has ever used, including aliases, maiden name, and nicknames. If you 

need extra space to complete this section, use the space provided in Part 7. Additional Information.

Adult Member of the Household's Contact Information 
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 2 of 9

Part 1. Information About an Adult Member of the Household (continued)

Adult Member of the Household's Biographical Information 

7. Daytime Telephone Number 8. Mobile Telephone Number (if any)

9. Email Address (if any)

► A14. Alien Registration Number (A-Number) (if any)

12. State or Province of Birth 13. Country of Birth

10. Date of Birth (mm/dd/yyyy) 11. City/Town/Village of Birth 

15. USCIS Online Account Number (if any)

►

You, the applicant or petitioner, must answer each of the following questions. See the Duty of Disclosure section in the Form I-600A 

or Form I-600 Instructions concerning your ongoing duty to disclose information in response to these questions. If you answer "Yes" 

to any of these questions, provide a certified copy of the documentation showing the final disposition of each incident which resulted 

in arrest, indictment, conviction, and/or any other judicial or administrative action and a written statement giving details, including any 

mitigating circumstances about each arrest. The written statement must be signed by the adult member of the household under penalty 

of perjury under U.S. law. The statement should include the following: 

 Duty of Disclosure

If signed outside the United States: “I declare (or certify, verify, or state) under penalty of perjury under the laws of the United 

States of America that this statement is true and correct.”

If signed within the United States (including territories, possessions, and commonwealths): “I declare (or certify, verify, or state) 

under penalty of perjury that this statement is true and correct.”

The written statement must also show the date of each incident; place the incident occurred (city/town, state/province, country); name 

of the police department or other law enforcement administration or other entity involved; date of incarceration and name of facility, if 

applicable; and include your (the applicant's/petitioner's) name and A-Number (if any) at the top of each sheet. In your written 

statement, you should also provide a description of any type of counseling, rehabilitation, or other information that you and the adult 

member of the household would like considered in light of this history.

16. Has the adult member of the household EVER, whether in or outside the United States:

A. Been investigated, arrested, cited, charged, indicted, convicted, fined, or imprisoned for breaking or 

violating any law or ordinance? (Answer "Yes" even if the record of the arrest, conviction, or other 

adverse criminal history was expunged, sealed, pardoned, or the subject of any other amelioration. Do 

not include traffic violations, except for violations for driving or operating a vehicle while intoxicated or 

while impaired by or under the influence of alcohol or other intoxicant.)

Yes No

B. Received a pardon, amnesty, rehabilitation decree, other act of clemency, or similar action? Yes No

Received a suspended sentence, been placed on probation or parole, or in an alternative sentencing or 

rehabilitation program, such as diversion, deferred prosecution, deferred or withheld adjudication, or 

expungement of a criminal charge?

Been the subject of any investigation at any time, even if closed or unsubstantiated, by any child welfare 

agency, court, or other official authority in any state or foreign country concerning the abuse or neglect 

of any child?

C.

D.

Yes No

Yes No
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 3 of 9

Part 2. Adult Member of the Household's Statement, Certification, Duty of Disclosure, and Signature

Notice to the Adult Member of the Household: By signing this Form I-600A/I-600, Supplement 1, you agree that U.S. Citizenship and 

Immigration Services (USCIS) may disclose to the applicant/petitioner or the applicant's/petitioner's adoption service providers, if 

applicable, information that USCIS may obtain about you that is relevant to the adjudication of the applicant's Form I-600A or petitioner's 

Form I-600, even if the Privacy Act, 5 USC 552a, might otherwise prevent disclosure of the information without your consent.

NOTE: If you, an adult member of the household, knowingly and willfully falsify or conceal a material fact or submit a false 

document in support of this Supplement 1, USCIS will deny the Form I-600A/I-600 filed for this case and may deny any other USCIS 

benefits requested by the prospective adoptive parents.

A.

B.

I can read and understand English, and I have read and understand every question and instruction on this supplement and 

my answer to every question.

The interpreter named in Part 5. has read to me every question and instruction on this supplement and my answer to 

and I understood everything.

every question, in , a language in which I am fluent, 

At my request, the preparer named in Part 6.,

2.

,

prepared this supplement for me based only upon information I provided or authorized.

1. Adult Member of the Household's Statement Regarding the Interpreter (Select the box for either Item A. or B.)

Adult Member of the Household's Statement Regarding the Preparer (if applicable)

Adult Member of the Household's Certification

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may 

require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any 

and all of my records that USCIS may need to determine the suitability and eligibility of the applicant or petitioner as an adoptive 

parent.

I certify, under penalty of perjury, that I provided or authorized all of the information in this supplement, I understand all of the 

information contained in, and submitted with, this supplement, and that all of this information is complete, true, and correct.

I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records, to 

other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

Adult Member of the Household's Duty of Disclosure

Adult Member of the Household's Statement

I understand the ongoing duty to disclose information concerning any change of circumstance, as described in the Form I-600A and/or 

Form I-600 Instructions, and I agree to notify the applicant, petitioner, home study preparer, and USCIS of any new information that I 

am required to disclose.

Adult Member of the Household's Signature

3. Adult Member of the Household's Signature Date of Signature (mm/dd/yyyy) 
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 4 of 9

Part 3. Information About You, the Applicant/Petitioner

1. Family Name (Last Name) Given Name (First Name) Middle Name (if applicable)

► A6. A-Number (if any)

2. Date of Birth (mm/dd/yyyy) 3. City/Town/Village of Birth 

4. State or Province of Birth 5. Country of Birth

1.

B.

I can read and understand English, and I have read and understand every question and instruction on this supplement and 

my answer to every question.

question in

The interpreter named in Part 5. read to me every question and instruction on this supplement and my answer to every 

, a language in which I am fluent, 

and I understood everything.

At my request, the preparer named in Part 6.,

prepared this supplement for me based only upon information I provided or authorized. 

,

2.

Part 4. Applicant's/Petitioner's Statement, Certification, and Signature

Applicant's/Petitioner's Statement

NOTE: If you or any adult member of the household knowingly and willfully falsify or conceal a material fact or submit a false 

document with your Form I-600A/I-600, Supplement 1, USCIS will deny your Form I-600A or Form I-600 and may deny any USCIS 

benefit you request.

Applicant's/Petitioner's Statement Regarding the Interpreter (Select the box for either Item A. or B.)

A.

Applicant's/Petitioner's Statement Regarding the Preparer (if applicable)

7. Daytime Telephone Number

8. Mobile Telephone Number (if any) 9. Email Address (if any)

10. USCIS Online Account Number (if any)

►
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 5 of 9

Applicant's/Petitioner's Signature

Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may 

require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any 

and all of my records that USCIS may need to determine my suitability and eligibility as an adoptive parent.

Applicant's/Petitioner's Signature Date of Signature (mm/dd/yyyy) 

I furthermore authorize release of information contained in this supplement, in supporting documents, and in my USCIS records, to 

other entities and persons where necessary for the administration and enforcement of U.S. immigration law.

3.

1. Interpreter's Family Name (Last Name) Interpreter's Given Name (First Name)

Interpreter's Full Name

2. Interpreter's Business or Organization Name (if any)

Part 5. Interpreter's Contact Information, Certification, and Signature

If the adult member of the household and/or applicant/petitioner used an interpreter to read and complete this supplement, provide the 

following information about the interpreter.

I certify, under penalty of perjury, that I provided or authorized all of the information in my supplement, I understand all of the 

information contained in, and submitted with, my supplement, and that all of this information is complete, true, and correct.

Applicant's/Petitioner's Certification

Interpreter's Mailing Address

3.

City or Town State ZIP Code

Province Postal Code Country

Street Number and Name Apt. Ste. Flr. Number

Interpreter's Contact Information

Interpreter's Daytime Telephone Number

Interpreter's Email Address (if any)

4.

6.

5. Interpreter's Mobile Telephone Number (if any)

Part 4. Applicant's/Petitioner's Statement, Certification, and Signature (continued)
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 6 of 9

Part 5. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Certification

7. Interpreter's Signature Date of Signature (mm/dd/yyyy)

Interpreter's Signature

Preparer's Full Name

1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name)

2. Preparer's Business or Organization Name (if any)

Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Supplement, If 

Other Than the Applicant/Petitioner or Adult Member of the Household

If you, the applicant/petitioner or adult member of the household used a preparer to complete this supplement, provide the following 

information about the preparer.

I certify, under penalty of perjury, that:

I am fluent in English and , which is the same language specified in Parts

2. and 4., Item B. in Item Number 1., and I have read to this adult member of the household and/or applicant/petitioner in the 

identified language every question and instruction on this supplement and his or her answer to every question. The adult member of 

the household and applicant/petitioner informed me that he or she understands every instruction, question, and answer on the 

supplement, including the Adult Member of the Household's Certification and the Applicant's/Petitioner's Certification, and has 

verified the accuracy of every answer.

Preparer's Mailing Address

Street Number and Name Apt. Ste. Flr. Number

City or Town State ZIP Code

Province Postal Code Country

3.

 Preparer's Contact Information

Preparer's Daytime Telephone Number Preparer's Mobile Telephone Number (if any)

Preparer's Email Address (if any)

4.

6.

5.
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 7 of 9

Preparer's Statement

I am not an attorney or accredited representative but have prepared this supplement on behalf of the adult member of the 

household and/or applicant/petitioner and with the adult member of the household's and/or applicant's/petitioner's consent. 

I am an attorney or accredited representative and my representation of the adult member of the household and/or

applicant/petitioner in this case extends does not extend beyond the preparation of this supplement.

7.

B.

Preparer's Signature Date of Signature (mm/dd/yyyy)

Preparer's Certification

Preparer's Signature

By my signature, I certify, under penalty of perjury, that I prepared this supplement at the request of the applicant/petitioner and/or 

adult member of the household. The applicant/petitioner and adult member of the household then reviewed this completed 

supplement and informed me that he or she understands all of the information contained in, and submitted with, this supplement, 

including the Adult Member of the Household's Certification and the Applicant's/Petitioner's Certification, and that all of this 

information is complete, true, and correct. I completed this supplement based only on information that the applicant/petitioner and/or 

adult member of the household provided to me or authorized me to obtain or use. 

8.

Part 6. Contact Information, Declaration, and Signature of the Person Preparing this Supplement, If 

Other Than the Applicant/Petitioner or Adult Member of the Household (continued)

A.
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 8 of 9

Part 7. Additional Information

If you need extra space to provide any additional information within this supplement, use the space below. If you need more space 

than what is provided, you may make copies of this page to complete and file with this supplement or attach a separate sheet of paper. 

If you attach a separate sheet of paper, type or print your full name and A-Number (if any) at the top of each sheet; indicate the Page 

Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. 

D.

1.

3. B.

B.

B.

B.

C.

C.

C.

C.

Page Number Part Number Item Number

2. A-Number (if any) ►AD.

4. Page Number Part Number Item Number

Family Name (Last Name) Given Name (First Name) Middle Name 

D.

5. Page Number Part Number Item Number

D.

6. Page Number Part Number Item Number

A.

A.

A.

A.
Form I-600A/I-600 Sup 1 Edition 04/01/24 Page 9 of 9

AUTHORITIES: The information requested on this supplement, and the associated evidence, is collected under the Immigration and 

Nationality Act sections 101(b)(1)(F), 201, and 204, and 8 CFR sections 204.3, 204.301, and 204.311.

DHS Privacy Notice

PURPOSE: This supplement must be completed for every adult member of the household, other than the applicant/petitioner and 

spouse (if married). USCIS may request submission of this supplemental form for additional individuals. The purpose of this 

supplement is to collect information on any individual who has the same residence as the applicant/petitioner and is 18 years of age or 

older on or before the date the applicant/petitioner files Form I-600A or Form I-600, any household member who has not yet turned 18 

years of age before the applicant/petitioner files Form I-600A or Form I-600, and any individual who does not actually live at the 

same residence as the applicant/petitioner, but whose presence USCIS deems relevant to determine the applicant/petitioner's suitability 

to adopt. USCIS will determine suitability by conducting background and security checks on adult household members to assist in 

assessing the suitability of the applicant/petitioner.

DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, and any 

requested evidence, may delay a final decision or result in denial of the underlying adoption-related application and/or petition.

ROUTINE USES: The Department of Homeland Security (DHS) may share the information you provide on this supplement and any 

additional requested evidence with other Federal, state, local, and foreign government agencies and authorized organizations. DHS 

follows approved routine uses described in the associated published system of records notices [DHS/USCIS-001 - Alien File, Index, 

and National File Tracking System and DHS/USCIS-005 - Inter-Country Adoptions Security] and the published privacy impact 

assessments [DHS/USCIS/PIA-007(b) Domestically Filed Intercountry Adoptions Applications and Petitions and 

DHS/USCIS/PIA-051 Case and Activity Management for International Operations] which you can find at www.dhs.gov/privacy. 

DHS may also share this information, as appropriate, for law enforcement purposes or in the interest of national security.

PRIVACY ACT WAIVER: Except as permitted by the Privacy Act, 5 USC 552a, applicable routine uses, and information related to 

adult members of your household as noted below, USCIS may not disclose or give access to any information or record relating to any 

applicant/petitioner, spouse (if married), or adult member of your household to any individual or entity other than that person, 

including but not limited to an accredited agency, approved person, exempted provider, supervised provider, or other adoption service 

provider, unless you give written consent.

If you want to give consent for USCIS to disclose information about your case to an individual or entity, you must complete Form 

I-600A/I-600, Supplement 2, Consent to Disclose Information. You are not required to give this consent to file Form I-600.

NOTICE TO ADULT MEMBERS OF THE HOUSEHOLD: You are not the prospective adoptive parent who is filing Form 

I-600A application or Form I-600 petition. As an adult member of the prospective adoptive parent's household, however, information 

about you may be relevant to the adjudication of the prospective adoptive parent's Form I-600A or Form I-600. Under 

8 CFR 103.2(b)(16), the prospective adoptive parent is entitled to review any information that may be used to deny a Form I-600A or 

Form I-600. By signing the Form I-600A/Form I-600, Supplement 1, you consent to USCIS disclosing to the prospective adoptive 

parents, adoption service provider, home study preparer, if applicable, and any individual or entity identified by the prospective 

adoptive parent, if applicable, information that USCIS may obtain about you that is relevant to the adjudication of the prospective 

adoptive parent's Form I-600 or Form I-600A, even if the Privacy Act, 5 USC 552a, might otherwise prevent disclosure of the 

information to the prospective adoptive parents.