Table of Changes G-845 Supplement

TABLE OF CHANGES

FORM G-845 SUPPLEMENT

OMB No. 1615 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1 – To be completed by the submitting agency - Header	To be completed by the submitting agency	Section A. To Be Completed by Registered Agency Only
Page 1 – To be completed by the submitting agency – To: address section	To: U.S. Citizenship and Immigration Services Applicant’s Name Date (mm/dd/yyyy) Alien Registration Number or I-94 Social Security Number Phone Number	To: U.S. Citizenship and Immigration Services (USCIS) (fillable space) Attn: USCIS SAVE Program Status Verification Office
Page 1 – To be completed by the submitting agency – From: address section	From: Typed or Stamped Name and Address of Submitting Agency USCIS may use Agency address with a No. 10 window envelope	From: Type or Stamp Name and Address of Registered Agency (fillable space) Print clearly since USCIS may use above agency address with a No. 10 window envelope.
Page 1 – To Be Completed by USCIS section – bottom left column	Note: This G-845 Supplement Form must be used in conjunction with Form G-845 to request verification: it may not 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.	___________________________________________ Note: A completed Form G-845 Supplement must be used with a Form G-845 to request verification - it may not be used alone. The information on this form concerns eligibility for Federal, State, and local public benefits under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. 104-193. ___________________________________________ (Move to Page1 left column, under the ‘window envelope’ header/address section. )
Page 1 – To be completed by the submitting agency	New Section below Note (above)	Immigration Document Number: Alien Registration Number (A-Number): I-94 (Arrival-Departure Record) Number: Other immigration number (if A-Number/I-94 Number is not available): Identify document containing the other immigration number:

TABLE OF CHANGES (p.2)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 1 – To be completed by the submitting agency	New Section below Note (above)	2. Applicant’s name as shown on the immigration document (Last, First, Middle)
Page 1 – To be completed by the submitting agency	NEW	3. Date of Birth (mm/dd/yyyy)
Page 1 – To be completed by the submitting agency	NEW	4. Social Security Number:
Page 1 – To be completed by the submitting agency	NEW	5. Name of Agency Official __________________________________
Page 1 – To be completed by the submitting agency	NEW	6. Telephone Number (include area code) __________________________________
Page 1 – To be completed by the submitting agency	NEW	7. Date (mm/dd/yyyy) __________________________________
Page 1 – To be completed by the submitting agency – Complete the following items:	Complete the following items: For SSA Use Only:	_____________________________________________________ 8. Check the box(es) corresponding to the information your agency requests: □ 1. Immigration Status □ 3. Special Benefit Provision for Certain Victims of Abuse □ 2. Citizenship Status □ 4. Affidavit of Support For SSA Use Only: □ USCIS to verify Cuban/Haitian Entrants by filling out Section C. □ SSA-8510 attached (To be used only for applicants with proceedings pending with EOIR). □ RSDI Claim: USCIS to complete Items B.4(a) and (b). □ Status of this applicant as of 8/22/1996 is required. USCIS to complete Item C.1.

TABLE OF CHANGES (p. 3)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 2 – USCIS Stamp Box	The USCIS Stamp box is in the bottom right hand corner of the page.	USCIS Stamp box to be moved to the bottom right hand corner of Page 1 under the Agency Comments box.
Page 2 – Registered Agency Comment Box	New	Box at top of page for Registered Agency Comments.
Page 2 – To be completed by USCIS - section	To be completed by USCIS	Section B. To Be Completed by USCIS (Move to page 2.)
Page 2 – To be completed by USCIS - section	New	USCIS RESPONSES: After review of the documents and/or information submitted, and/or our records, we find that the document appears valid and relates to a/an: (Move under new Section B, page 2.)
Page 2 – To be completed by USCIS – section, 1. Immigration Status	Delete the following sentence: From the document or information . . .	N/A
Page 2 – To be completed by USCIS – section, 1. Immigration Status	1. □ 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.)	□ a. Lawful Permanent Resident (LPR) alien of the United States. Requesting agency must chose the date they need to make their benefit determination (check only one) □ Effective Date of LPR status/rollback date: ______ (mm/dd/yyyy) □ Date Adjustment to LPR approved: ­­­­­_______ (mm/dd/yyyy) □ Date Form I-485 Application Approved: ______ (mm/dd/yyyy) (If alien adjusted to LPR status from status checked above in the past 7 years, complete b, c, d, g, h, i or j below.)
Page 2 – To be completed by USCIS – section, 1. Immigration Status	□ b. Refugee admitted to the United States under Section 207 of the INA. (Complete Item 2 below.)	□ b. Refugee admitted to the United States under section 207 of the Immigration and Nationality (INA). Date of admission as refugee: ____________________ (mm/dd/yyyy)
Page 2 – To be completed by USCIS – section, 1. Immigration Status	□ c. Asylee under Section 208 of the INA. (Complete Item 3 below.)	□ c. Asylee under section 208 of the INA. Date asylum granted: ___________________ (mm/dd/yyyy)
Page 2 – To be completed by USCIS – section, 1. Immigration Status	□ d. Alien whose deportation has been withheld . . .	No changes.

TABLE OF CHANGES (p. 4)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 2 – To be completed by USCIS – section, 1. Immigration Status	□ 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.)	□ e. Alien paroled into the United States under section 212(d)(5) of the INA for a period of at least 1 year. Date parole granted: __________________ (mm/dd/yyyy) Date parole expires: _____________­­______(mm/dd/yyyy)
Page 3 – To be completed by USCIS – section, 1. Immigration Status	□ f. Conditional Entrant pursuant to Section 203(a)(7) of the INA prior to April 1, 1980.	□ f. Conditional entrant under section 203(a)(7) of the INA prior to April 1, 1980. Date status granted:__________________ (mm/dd/yyyy)
Page 3 – To be completed by USCIS – section, 1. Immigration Status	□ g. American Indian born in Canada to whom the provisions of Section 289 of the INA apply.	□ g. American Indian born in Canada to whom the provisions of section 289 of the INA apply. Date status recognized: __________________ (mm/dd/yyyy)
Page 3 – To be completed by USCIS – section, 1. Immigration Status	□ h. Cuban/Haitian Entrant as defined in Section 501 (e) of the Refugee Education Assistance Act of 1980. (Complete Item 3 below.)	□ h. Alien paroled into the United States as a Cuban/Haitian entrant, as defined in section 501 (e) of the Refugee Education Assistance Act of 1980. Date of parole/entry: _________­_____ (mm/dd/yyyy)
Page 3 – To be completed by USCIS – section, 1. Immigration Status	□ i. Amerasian immigrant, pursuant to Section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988. (Complete Item 2 below.)	□ i. Amerasian immigrant, under section 584 of the Foreign Operations, Export Financing and Related Programs Appropriations Act of 1988. Date of entry: _________________ (mm/dd/yyyy)
Page 3 – To be completed by USCIS – section, 1. Immigration Status	□ j. Other (indicate status):______________________________	□ j. Alien classified as an Iraqi/Afghan Special Immigrant admitted under section 101(a)(27) of the INA. Date of entry:______________(mm/dd/yyyy) Date status granted:_____________(mm/dd/yyyy) Class of Admission (COA):___________________
Page 3 – To be completed by USCIS – section, 1. Immigration Status	NEW	□ k. Other (indicate status):___________________________ Date status granted:____________________(mm/dd/yyyy) COA (if applicable):__________________________
Page 3 – To be completed by USCIS – section, 2.	2. Date alien entered the United States:________	2. Citizenship Status: □ U.S. Citizen. Only for SSA RESDI Claims, SSA to fill in requested dates. Status from: ________ (mm/dd/yyyy) to: ______ (mm/dd/yyyy) Response: __________ (mm/dd/yyyy)

TABLE OF CHANGES (p. 5)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 3 – To be completed by USCIS – section, 3.	3. Date status was granted:___________________	3. Special Benefit Provision for Certain Victims of Abuse: □ a. Alien obtained lawful permanent (or conditional) resident status as the spouse, child or widow(er) of a U.S. citizen. Date status granted:__________________(mm/dd/yyyy) □ b. Alien obtained lawful permanent (or conditional) resident status as the spouse, child or unmarried son or daughter of a lawful permanent resident alien. Date status granted:___________(mm/dd/yyyy) □ c. Alien did not obtain status as described in 3(a) or 3(b) above.
Page 4 – To be completed by USCIS – section, 4.	4. Date status expires:___________________	4. Affidavit of Support: □ a. Alien was sponsored on Form I-864, Affidavit of Support, under section 213A of the INA. Service receipt date:_________(mm/dd/yyyy) Sponsor’s Name: Last Name_______________________________________________ First Name ______________________________________________ Middle Name ____________________________________________ Sponsor’s Social Security Number: _______________________________________________ Sponsor’s Address: ________________________________________________ ________________________________________________ ________________________________________________ Name of Joint Sponsor: Last Name_______________________________________________ First Name ______________________________________________ Middle Name ____________________________________________ Joint Sponsor’s Social Security Number: ________________________________________________ Joint Sponsor’s Address: ________________________________________________ ________________________________________________ □ See attached for information on additional joint sponsor(s). □ b. Alien was not sponsored on Form I-864.
Page 3 – To be completed by USCIS – section 5	Delete: 5. Citizenship Status	N/A
Page 3 – To be completed by USCIS – section 6	Delete: 6. Special Benefit Provision for Certain Victims of Abuse	N/A

TABLE OF CHANGES (p. 6)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 3 – To be completed by USCIS – section 7	Delete: 7. Affidavit of Support	N/A
Page 3 – Paperwork Reduction Act	Header and notice on bottom left column of second page.	Move header and notice to bottom of separate Instructions Page – full width of page.
Page 3 – USCIS Stamp Box	Text box containing “USCIS Stamp” located at the bottom right corner of page 2.	Moved text box containing “USCIS Stamp” to bottom right corner of Page 1, under agency comments box.
Page 4 - NEW Section Header C.	New	Section C. To Be Completed by USCIS for SSA USCIS RESPONSES: After review of the documents and/or information submitted, and/or our records, we find that the document appears valid and relates to:
Page 4 - NEW Section C. 1	New	Immigration Status of alien on 8/22/1996: (enter status as of this date or “not applicable” as appropriate Status at Entry: ___ COA: _______________________
Page 4 - NEW Section C. 2.	New	2. Immigration Status of Cuban/Haitian nationals:
Page 4 – NEW Section C.2.	New	□ a. Is the Alien a Cuban or Haitian National? (Select only one) □ Yes □ No If not C/H, STOP
Page 4 - NEW Section C. 2.	New	□ b. Alien paroled into the United States as a Cuban/Haitian entrant (status pending) as defined in Sec. 501 (e) of the Refugee Education Assistance Act of 1980, on or after 04/21/2980 (Category 1A), or a Cuban Haitian Entrant paroled on or after October 10, 2980 (Category 1B). SSA to fill in requested dates. Status from: _________ (mm/dd/yyyy) to: ________ (mm/dd/yyyy) Response: ______________
Page 5 - NEW Section C. 2.	New	□ c. Alien paroled into the United States who has not acquired any other status under the INA. (Category 2A) SSA to fill in requested dates. Status from: _________ (mm/dd/yyyy) to: ________ (mm/dd/yyyy) Response: ______________
Page 5 - NEW Section C. 2.	New	□ d. Alien paroled into the United States in the custody of Federal, State, or local enforcement authorities for law enforcement purposes. Date of entry: ______________ (mm/dd/yyyy)

TABLE OF CHANGES (p. 7)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

February 14, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Page 5 - NEW Section C. 2.	New	□ e.1. Alien whose asylum application filed under section 208 of the INA is pending with DHS. (Category 2C) Date asylum application filed:_________________ (mm/dd/yyyy) e.2. Alien whose asylum application filed under section 208 of the INA is pending with EOIR. (Category 2B) SSA attach Form SSA-8510 Date asylum application referred to EOIR: _________________ (mm/dd/yyyy)
Section C. 2.		removal proceedings under the INA but has no final order. (Category 2B) Date alien placed into proceedings:______________(mm/dd/yyyy)
Page 5 - NEW Section C. 2.	New	□ g. Person does not meet any of the categories described above.
Page 5 - NEW Section C. 3.	New	□ a. Alien is subject to an order of removal which is final, non-appealable, and legally enforceable. Date order became final: _______________(mm/dd/yyyy) □ b. Alien is subject to an order of supervision after an order of removal. Date of order: ­­­­­­­­­­­­_____________ (mm/dd/yyyy)
Page 5 – NEW Section C.3.	New	□ c. Alien is NOT subject to an order of removal which is final, non-appealable, and legally enforceable.
Page 5 - NEW Section C. 4.	New	□ a. Cuban or Haitian entrant who adjusted to LPR status under: □ NACARA □ HRIFA □ IRCA of 1986 □ CAA of 1966 Date Form I-485 was approved: __________________ (mm/dd/yyyy) COA:__________________
Page 5 - NEW Section C. 4.	New	□ b. Alien is NOT an LPR or adjusted under a different section of law.
Page 6 – NEW Text Box Section D. USCIS Comments	New	Text Box full width of page located after Section C: Comments:
NEW Instructions Page 1	New	New Instructions Page entitled, Instructions for G-845 Supplement, Document Verification Request
Instructions Page 1 –Header section	New	Instructions Read these instructions carefully to properly complete this form. If you do not follow the instructions, U.S. Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) Program may return this form, which may delay processing. (Heading at top center of page – similar to format of I-130 Instructions.)

TABLE OF CHANGES (p. 8)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Instructions Page 1 –What Is The Purpose Header and section	New	What Is The Purpose Of This Form? An agency that is registered with the USCIS SAVE Program may file this form with Form G-845, Document Verification Request, to request more detailed information on immigration status, citizenship and sponsorship.
Instructions Page 1 –Who May File This Form Header and section	New	Who May File This Form? Any agency that has executed a Memorandum of Agreement with the USCIS SAVE Program.
Instructions Page 1 – General Instructions Header and section	New	General Instructions This form must be submitted with Form G-845 to request additional information. This form cannot be used alone. The information on this form concerns eligibility for Federal, State, and local public benefits under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. 104-193.
Instructions Page 1 – General Instructions section	New	A separate Form G-845 and Form G-845 Supplement must be completed for each applicant and must include copies of documents only for that individual. If a family unit applies for a benefit, submit a separate Form G-845 and G-845 Supplement for each family member. When completing Form G-845 Supplement, type or print legibly in black ink (unless electronically generated).
Instructions Page 1 – General Instructions section	New	Submit copies (front and back) of the alien’s original documentation. Ensure that copies are legible. Make certain a complete return address has been entered in the “From” portion of the form and all items in Section A have been completed. (SAVE may use this portion of the form for your address in a number 10 window envelope.)
Instructions Page 1 – General Instructions section	New	Section A. To Be Completed by Registered Agency Only 1. In the “To” section: stamp or legibly write the mailing address of the agency’s assigned Status Verification Office; this can be found at www.uscis.gov/save. 2. In the “From” section: stamp or legibly write the registered agency name and mailing address with the Zip Code.
Instructions Page 1 – General Instructions section – II.	New	Complete items numbered 1 through 8.

TABLE OF CHANGES (p. 9)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

February 14, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
Instructions Page 1 – General Instructions section – II.	New	Enter the Alien Registration Number (A-Number) or the I-94 Arrival-Departure Record Number in the space provided, or both the A-Number and I-94 Number if both numbers are listed on the provided document. The A-Number is the letter “A” followed by a series of 7, 8 or 9-digit number. The I-94 Number found on Form I-94 and is 11 digits. (Check the front and back of the Form I-94 document. If the A-Number appears, record that number when requesting information instead of the I-94 Number because the A-Number refers to the most integral record available.) If the A-Number or I-94 Number is not available, enter another immigration number such as the Student and Exchange Visitor Information System (SEVIS) Number or Certificate of Citizenship document number on the line marked “Other immigration number.” Provide the name of the immigration document that contains this immigration number on the line below. 2. Enter the applicant’s last, first, and middle name. 3. Enter the applicant’s date of birth in the format indicated. 4. Enter the applicant’s social security number, if applicable. 5 – 6. Enter the name of the agency official and telephone number. 7. Enter the date the Form G-845 Supplement is completed. 8. Check the corresponding box for the verification requested.
Instructions Page 1 – General Instructions Section III.		Registered Agency Comments Box (Optional): Agency may enter additional information about the immigration verification requested.
Instructions Page 2- General Instructions Section – IV.	New	Special Instructions For SSA in Section B and C Section B. item 2 - Enter dates status information is requested for SSA’s Retirement, Survivors and Disability Insurance (RSDI). Section C. item 2b. and 2c. – Enter dates status information is requested.
Instructions Page 2 – Processing Information section	New	Processing Information Upon receipt, the SAVE Program Status Verification Office will review the form for completeness, including submission of any attached documents. Please be aware that if the Form G-845 Supplement is not completely filled out, USCIS will return the form to you with no verification response. Please be aware that if the Form G-845 Supplement is submitted

TABLE OF CHANGES (p. 10)

FORM G-845 SUPPLEMENT

OMB No. 1615-0101

May 19, 2011

LOCATION	CURRENT VERSION	PROPOSED VERSION
		without Form G-845 or a copy of the applicant’s original documentation, USCIS will return it to you with no verification response.
Instructions Page 2 - Paperwork Reduction Act Notice	Moved from page 2 of the Form G-845 Supplement.	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, Office of the Executive Secretariat, 20 Massachusetts Avenue, N.W., Washington, DC 20529-2020, OMB No. 1615-0101; Expires 07/31/2011. Do not mail your verification request to this address.