Document Verification Request and Document Verification Request Supplement

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

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Instructions for Form G-845 Supplement,
Document Verification Request Supplement

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

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.

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.

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.

For Production

Who May File This Form?

Complete items numbered 1 through 8

Any agency that has executed a Memorandum of Agreement
with the USCIS SAVE Program.

1. 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 I-94
Number is found on Form I-94 and is 11 digits. (Check the
front and back of the Form I-94. 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 document
that contains this immigration number on the line below.

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.
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 Form G-845
Supplement for each family member.
When completing Form G-845 Supplement, type or print
legibly in black ink (unless electronically generated).
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.)

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.
Registered Agency Comments Box (Optional): Agency may
enter additional information about the immigration
verification request.

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

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Special Instructions for SSA in Sections B and C

1. Section B. item 2 - Enter dates status information is
requested for SSA's Retirement, Survivors and Disability
Insurance (RSDI).
2. Section C. item 2b. and 2c. - Enter dates status
information is requested.

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.

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 Products Division, Office of the Executive
Secretariat, 20 Massachusetts Avenue, N.W., Washington, DC
20529-2020; OMB No. 1615-0101. This form expires July 31,
2011. Do not mail your verification request to this address.

For Production

Please be aware that if the Form G-845 Supplement is
submitted without Form G-845 and a copy of the applicant's
original documentation, USCIS will return it to you with no
verification response.

USCIS Privacy Act Statement
The information provided in this form is subject to the Privacy
Act of 1974 ((5 U.S.C. § 552a) and must be protected from
unauthorized disclosure or secondary uses. In accordance with
the Privacy Act, the information collected and provided to
authorized agencies pursuant to this form is covered by the
System of Records Notice "DHS/USCIS-004 - Systematic
Alien Verification for Entitlements Program System of
Records" September 21, 2011, 76 FR 58525.

Form G-845 Supplement (Rev. 05/20/11) N Page 2