G-845 Document Verification Request

OMB No. 1615-0101; Expires 07/31/2011

DRAFT - Not For
Form Production
G-845, Document Verification Request

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

Section A. To Be Completed by Registered Agency Only
To: U.S. Citizenship and Immigration Services (USCIS)

9. Check all that apply:

Attn: USCIS SAVE Program Status Verification Office

a. Photocopy of primary immigration document
attached. Ensure copies are legible. If there is
print on both sides of the immigration document,
attach a copy of front and back.

From: Type or Stamp Name and Address of Registered Agency

b. Other Information Attached (specify documents):

Print clearly since USCIS may use above agency address with a
No. 10 window envelope.

1.

Immigration Document Number

10. Benefit
TANF

Unemployment Insurance

Education Grant/
Loan/ Work Study

Employment
Authorization

Food Stamps

Social Security Number

Other immigration number (if A-Number/I-94 Number not

Housing Assistance

SSI or RSDI

available):

Medicaid/Medical
Assistance

Driver's License/ID

Alien Registration Number (A-Number):

AI-94 (Arrival-Departure Record) Number:

Identify document containing the other immigration
number:
2. Applicant's name as shown on the immigration document
(Last, First, Middle):

3. Nationality

4. Date of Birth (mm/dd/yyyy):

Background Check
Other (specify below)

11. Name of Agency Official:

12. Title of Agency Official:

5. Social Security Number:
13. Telephone Number (include area code):
6. Student and Exchange Visitor Information System (SEVIS)
Number:
7. Case Verification Number:

14. Fax Number (include area code):
15. Date (mm/dd/yyyy):

8. Registered Agency Case Number:

Form G-845 (Rev. 02/14/11) N

DRAFT - Not For Production
Section A. To Be Completed by Registered Agency Only (continued)
Registered Agency Comments

Section B. To Be Completed by USCIS
USCIS RESPONSES: After review of the documents

7.

and/or information submitted, and/or of our records, we
find that the document appears valid and relates to a/an:
1. Lawful Permanent Resident alien of the United States.

Alien paroled into the United States under
section 212 of the Immigration and Nationality Act
(INA).
a. No expiration (Indefinite)
b. Parole granted on (mm/dd/yyyy):

2. Conditional Resident alien of the United States.
3. Alien employment authorized in the United States as
indicated:

c. Parole expires on (mm/dd/yyyy):

a. No expiration (indefinite)
b. Expires on (mm/dd/yyyy):

8.

Cuban/Haitian entrant of the United States.

c. Prior employment authorization date(s):

9.

Conditional entrant of the United States.

10. Nonimmigrant alien.
(Specify type or class below):
11. American Indian born in Canada to whom the
provisions of section 289 of the INA apply. Date
status recognized (mm/dd/yyyy):
4. Alien not employment authorized in the United
States.
5. Alien has an application pending for (specify USCIS
benefit):

12. U.S. Citizen.

OTHER USCIS RESPONSES:
13. USCIS is searching indices for further information.

6. Alien granted asylum or refugee status in the United
States.

14. This document is not valid because it appears to be:
(Check all that apply)
a. Expired

b. Altered

c. Counterfeit

Form G-845 (Rev. 02/14/11) N Page 2

DRAFT - Not For Production
Section C. USCIS Comments
1. Unable to process request without an original consent
of disclosure statement signed by the applicant.
Resubmit request.

USCIS Stamp

2. No determination can be made from the information
submitted. Obtain copy of the original alien
registration document. Resubmit request.
3. No determination can be made without seeing both
sides of the documents submitted. Resubmit request.
4. Cannot read document copy. Resubmit request.
5. Other:

Form G-845 (Rev. 02/14/11) N Page 3