G-845 Supplement Document Verification Request Supplement

DRAFT - Not For Production
Form G-845 Supplement, Document

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

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

Verification Request Supplement

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

5. Name of Agency Official

Attn.: USCIS SAVE Program Status Verification Office

6. Telephone Number (include area code)

7. Date (mm/dd/yyyy):
From: Type or Stamp Name and Address of Registered Agency

8. Check the box(es) corresponding to the information your
agency requests:
1. Immigration Status
2. Citizenship Status

Print clearly since USCIS may use above agency address
with a No. 10 window envelope.
NOTE: A completed Form G-845 Supplement must be used
with a completed 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.
1. Immigration Document Number
Alien Registration Number (A-Number):
► AI-94 (Arrival-Departure Record) Number:

3. Special Benefit Provision for Certain Victims of
Abuse
4. Affidavit of Support

For SSA Use Only:
USCIS to verify Cuban/Haitians Entrants by filling out
Section C.
SSA-8510 attached (To be used only for applicants
with proceedings pending with EOIR).
RSDI Claim: USCIS complete Items B. 4(a) and (b).
Status of this applicant as of 8/22/1996 is required
USCIS to complete Item C. 1.

►
Other immigration number (if A-Number/I-94 Number is
not available):
Identify document containing the other immigration

USCIS Stamp

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

3. Date of Birth (mm/dd/yyyy):
4. Social Security Number:

Form G-845 Supplement (Rev. 05/20/11) N

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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 and/or information submitted, and/or our records, we find that the document
appears valid and relates to a/an:
1. Current Immigration Status (Check all that apply):
a. Lawful Permanent Resident (LPR) alien of the United States. Requesting agency must choose the date that they need to
make their benefit determination (check only one):
(mm/dd/yyyy)

Effective Date of LPR status/rollback date:

(mm/dd/yyyy)

Date Adjustment to LPR approved:

(mm/dd/yyyy)

Date Form I-485 Application Approved:

(If alien adjusted to LPR status from status in the past 7 years, complete b, c, d, g, h, i, or j below.)
b. Refugee admitted to the United States under section 207 of the Immigration and Nationality Act (INA).
Date of admission as refugee:

(mm/dd/yyyy)

c. Asylee under section 208 of the INA. Date asylum granted:

(mm/dd/yyyy)

d. Alien whose deportation has been withheld 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:

(mm/dd/yyyy)

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Section B. To Be Completed by USCIS (continued)
e. Alien paroled into the United States under section 212(d)(5) of the INA for a period of at least 1 year.
(mm/dd/yyyy)

Date parole granted:

(mm/dd/yyyy)

Date parole expires:

f. Conditional entrant under section 203(a)(7) of the INA prior to April 1, 1980.
Date status granted:

(mm/dd/yyyy)

g. American Indian born in Canada to whom the provisions of section 289 of the INA apply.
Date status recognized:

(mm/dd/yyyy)

h. Alien paroled into the United States as a Cuban/Haitian entrant, as defined in section 501(e) of the Refugee Education
(mm/dd/yyyy)

Assistance Act of 1980. Date of parole/entry:

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)

j. Alien classified as an Iraqi/Afghan special immigrant admitted under section 101(a)(27) of the INA.
(mm/dd/yyyy)

Date of entry:

Date status granted:

(mm/dd/yyyy)

Class of Admission (COA):
k. Other (indicate status):
Date status granted:
2. Citizenship Status:

(mm/dd/yyyy)

COA (if applicable):

U.S. Citizen.

Only for SSA RSDI Claims, SSA to fill in requested dates.
Status from:

(mm/dd/yyyy)

To:

(mm/dd/yyyy)

Response:
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.

Form G-845 Supplement (Rev. 05/20/11) N Page 3

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4. Affidavit of Support:
a. Alien was sponsored on Form I-864, Affidavit of Support, under section 213A of the INA.
(mm/dd/yyyy)

Service receipt date:
Name of Sponsor:

Name of Joint Sponsor:

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

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

Middle Name

Middle Name

Sponsor's Social Security Number:

Joint Sponsor's Social Security Number:

Sponsor's Street Address:

Joint Sponsor's Street Address:

b. Alien was not sponsored on Form I-864.
See attached for information on additional joint
sponsor(s).

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:
1. Immigration Status of alien as of 8/22/1996:
(enter status as of this date or "not applicable" as appropriate)
Status at Entry:

COA:

2. Immigration Status of Cuban/Haitian nationals:
a. Is the Alien a Cuban or Haitian national? (Select only one)

Yes

No If not C/H, STOP

b. Alien paroled into the United States as a Cuban/Haitian entrant (status pending) as defined in section 501 (e) of the Refugee
Education Assistance Act of 1980, on or after 04/21/1980 (Category 1A), or a Cuban Haitian entrant paroled on or after
October 10, 1980 (Category 1B).
SSA to fill in requested dates Status from:

(mm/dd/yyyy)

to:

(mm/dd/yyyy)

Response:

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Section C. To Be Completed by USCIS for SSA (Continued)
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:
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)

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)

f. Alien paroled into the United States who is the subject of removal proceedings under the INA but has no final order.
(Category 2B)
(mm/dd/yyyy)

Date alien placed into proceedings:

g. Person does not meet any of the categories described above.
3. Removal Proceedings:
a. Alien is subject to an order of removal which is final, non-appealable, and legally enforceable.
(mm/dd/yyyy)

Date order became final:

b. Alien is subject to an order of supervision after an order of removal.
Date of order:

(mm/dd/yyyy)

c. Alien is NOT subject to an order of removal which is final, non-appealable, and legally enforceable.
4. Adjusted to Lawful Permanent Resident
a. Cuban or Haitian entrant who adjusted to LPR status under:
NACARA

HRIFA

Date Form I-485 was approved:

IRCA of 1986

CAA of 1966

(mm/dd/yyyy)

COA:

b. Alien is NOT an LPR or adjusted under a different section of law.

Form G-845 Supplement (Rev. 05/20/11) N Page 5

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Section D. USCIS Comments
Comments:

Form G-845 Supplement (Rev. 05/20/11) N Page 6