Form Supplement to G-84 Supplement to G-84 Supplement to Document Verification Request

OMB No. 1615-0101; Expires 00/00/08

G-845 Supplement, Document
Verification Request Supplement

Department of Homeland Security
U.S. Citizenship and Immigration Services

To be completed by the submitting agency
To:

U.S. Citizenship and Immigration Services
Date (mm/dd/yyyy):

Applicant's Name (Last, First, Middle)

Alien Registration Number or I-94 Number

Phone Number (Include Area Code):

Social Security Number

(

)

From: Typed or Stamped Name and Address of Submitting Agency

Complete the following items:
For SSA Use Only:

#1

#2

Show 08/22/96 status in #1 j.

#3

#4

#5

#6

#7

Alleged 08/22/96 status:

To be completed by USCIS
1. Immigration Status (Check all that apply):
From the document or information submitted and/or a review of our records, we find that the person identified is a/an:
a.

Lawful Permanent Resident (LPR) alien of the United States.
(Complete b, c, d, g, h or i if alien adjusted to LPR status from one of those statuses in the past seven years.)

b.

Refugee admitted to the United States under Section 207 of the INA. (Complete Item 2 below.)

c.

Asylee under Section 208 of the INA. (Complete Item 3 below.)

d.

Alien whose deportation has been witheld under Section 243(h) of the INA (as in effect prior to April 1, 1997) or whose
removal has been withheld under Section 241(b)(3).
Date deportation or removal ordered withheld:

e.

Alien paroled into the United States under Section 212(d)(5) of the INA for a period of at least one year.
(Complete Items 3 and 4 below.)

f.

Conditional Entrant pursuant to Section 203(a)(7) of the INA prior to April 1, 1980.

g.

American Indian born in Canada to whom the provisions of Section 289 of the INA apply.

h.

Cuban/Haitian Entrant, as defined in Section 501(e) of the Refugee Education Assistance Act of 1980.
(Complete Item 3 below.)

i.

Amerasian immigrant, pursuant to Section 584 of the Foreign Operations, Export Financing and Related Programs
Appropriations Act of 1988. (Complete Item 2 below.)

j.

Other (indicate status):

2. Date alien entered the United States:
3. Date status was granted:
4. Date status expires:
Form G-845 Supplement (05/09/08)

To be completed by USCIS (Continued.)
5. Citizenship Status:
This document appears valid and relates to a U.S. citizen.
6. Special Benefit Provision for Certain Victims of Abuse:
a. This alien obtained Lawful Permanent (or Conditional) Resident Status as the spouse, child or widow(er) of a U.S.
citizen.
b. This alien obtained Lawful Permanent (or Conditional) Resident Status as the spouse, child or unmarried son or
daughter of a lawful permanent resident alien.
c. This alien did not obtain status as described in (a) or (b) above under Item 6.
7. Affidavit of Support:
a. This alien was sponsored on Form I-864, Affidavit of Support, under Section 213A of the INA.
Service receipt date:

(Complete Item 3 on Page 1.)

b. This alien was not sponsored on Form I-864.
Name of Sponsor

Sponsor's U.S. Social Security Number

Name of Joint Sponsor(s) (if any)

Joint Sponsor's U.S. Social Security Number

Joint Sponsor's Address

Sponsor's Address

NOTE: This supplement may be used in conjunction with Form G-845 to
request verification: it cannot be used alone. It reflects information that
may be relevant to eligibility for Federal, State and local public benefits
under the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996, P.L. 104-193.

See attached for information on additional joint
sponsor(s).
USCIS Stamp

Paperwork Reduction Act
An agency may not conduct or sponsor an information collection and a
person is not required to respond to a collection of information unless it
displays a currently valid OMB control number. The public reporting
burden for this collection of information is estimated at 5 minutes per
response, including the time for reviewing instructions and completing and
submitting the form. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for
reducing this burden, to: U.S. Citizenship and Immigration Services,
Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd
Floor, Suite 3008, Washington, DC 20529. OMB No. 1615-0101. Do not
mail your application to this address.
Form G-845 Supplement (05/09/08) Page 2