Form I-800 Supplement 1 Consent To Disclose Information {I-800}

Department of Homeland Security U.S. Citizenship and Immigration Services Form I-800, Supplement 1, Consent to Disclose Information For USCIS Use Only Remarks: START HERE - Type or Print (Use black ink) NOTICE Information that USCIS may have concerning your Form I-800, Petition to Classify Convention Adoptee as an Immediate Relative, 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 primary adoption service provider, you may give this consent by signing Form I-800, Supplement 1. You do not need to sign Form I-800, Supplement 1, in order to file Form I-800. Note: Your primary adoption service provider 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. Pursuant to the Privacy Act, 5 U.S.C. 552a, and 8 CFR 204.302, and in order to assist USCIS in the adjudication of Form I-800, I (we), the undersigned petitioner(s) filing Form I-800, 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 primary adoption service provider: Name of Primary Adoption Service Provider Point of Contact (contact person within the organization) Street Number and Name City State or Province Fax Number (if any) Zip/Postal Code Country Suite # Daytime Phone # (with area/country code) E-Mail Address (if any) I (We) understand that, by signing this supplement, I am (we are) authorizing USCIS to provide the primary adoption service provider noted above with copies of notices sent to me (us) about this case, and also to discuss all aspects of my (our) case, including the prior Form I-800A proceeding as well as this Form I-800 proceeding. 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. SPECIFY whether you are withdrawing the consent to disclosure that you gave on a prior Form I-800A, Supplement 2, Consent to Disclose Information, or Form I-800, Supplement 1, Consent to Disclose Information: Yes, I am (we are) withdrawing all prior consents to disclose. No, USCIS may continue to disclose information to any adoption service provider included on any prior Form I-800A, Supplement 2, or Form I-800, Supplement 1. 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-800, Supplement 1 03/10/17 N American LegalNet, Inc. www.FormsWorkFlow.com