Form G-845 Verification Request

Verification Request

USCIS
Form G-845

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

OMB No. 1615-0101
Expires: 01/31/2015

► START HERE - Type or print in black ink.

Part 1. Information From the Registered Agency

3.

Case Verification Number

NOTE: Only the Registered Agency should complete this
information.

4.

Date of Birth

5.

Social Security Number

6.

Student and Exchange Visitor Information System
(SEVIS) Number

7.

Citizenship or Nationality

(mm/dd/yyyy) ►

To: U.S. Citizenship and Immigration Services (USCIS)

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Attn: USCIS SAVE Program Status Verification Office

Stamp, type, or print the name, address, and ZIP Code of the
Registered Agency. (Print clearly since USCIS may use
agency address below with a No. 10 window envelope.)

From:

Documents Attached (Select all that apply)
8.a.

Photocopy of most recently issued immigration
document attached. Ensure copies are legible and
made from an original document. If the immigration
document is printed on both sides, attach a copy of
the front and back.

8.b.

Other Information Attached (Specify Documents)

Benefits Sought

Applicant Information

Immigration Document Number

1.a. Alien Registration Number (A-Number)

A-

1.b. Form I-94 Number (Arrival-Departure Record)
►
1.c. Other Immigration Number

1.d. Name or Form Number of Document Containing the
Other Immigration Number

Applicant's Full Name as Shown on the Immigration
Document

9.a.

Background Check

9.b.

Driver's License/ID

9.c.

Education Grant/Loan/Work Study

9.d.

Employment Authorization

9.e.

Food Stamps

9.f.

Housing Assistance

9.g.

Medicaid/Medical Assistance

9.h.

Social Security Number

9.i.

SSI or RSDI

9.j.

TANF

9.k.

Unemployment Insurance

9.l.

Other (Specify)

2.a. Last Name
2.b. First Name
2.c. Middle Name
Form G-845 01/08/12 N

Please see next page for additional information.

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Applicant's Last Name

Applicant's First Name

Part 1. Information From the Registered Agency
(continued)
Registered Agency Information
10.

Case Verification Number

Part 2. USCIS Responses
NOTE: Only USCIS should complete this information.
Upon review of these documents, information submitted, and
our records, we find the following for the applicant:

Registered Agency Case Number

1.

Lawful Permanent Resident of the United States

2.

Conditional Permanent Resident of the United
States
Applicant is employment authorized in the United
States as indicated:

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Full Name of Agency Official

3.

11.a. Last Name

11.b. First Name

No Expiration Date (Indefinite)

12.

Expiration Date
(mm/dd/yyyy) ►

Title of Agency Official

Previous Employment Authorization Dates

13.a. Daytime Telephone Number (Include Area Code)

Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy)

13.b. Extension Number (if applicable)

14.

Fax Number (if any) (Include Area Code)

15.

Date Request Completed
(mm/dd/yyyy) ►

16.

4.

Applicant is not employment authorized in the
United States

5.

Applicant has an application pending for the
following USCIS benefit:

6.

Applicant was granted asylum or refugee status in
the United States

7.

Applicant was paroled into the United States under
section 212 of the Immigration and Nationality Act
(INA).

Registered Agency Comments (if any)

No Expiration Date (Indefinite)
Parole Granted Date
(mm/dd/yyyy) ►
Parole Expiration Date
(mm/dd/yyyy) ►

8.

Conditional entrant of the United States

9.

Nonimmigrant (Specify type or class and expiration
date)
Type or Class

Expiration Date (mm/dd/yyyy)
10.
Form G-845 01/08/12 N

U.S. Citizen

Please see next page for additional information.

Page 2 of 3

Applicant's Last Name

Applicant's First Name

Part 2. USCIS Responses (continued)
11.

Cuban/Haitian entrant of the United States

12

American Indian born in Canada to whom the
provisions of INA 289 apply.
Date Status Recognized
(mm/dd/yyyy) ►

13.

Case Verification Number

3.

No determination can be made without seeing both
sides of the applicant's immigration document.
Attach copies (front and back) of the applicant's most
recently issued immigration document and submit a
new request.

4.

Copy provided of applicant's immigration document
is illegible. Submit a new request with legible
documents.

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Mexican Born Member of the Texas or Oklahoma
Band of Kickapoo Indians
a.

I-872 Issuance Date:
(mm/dd/yyyy) ►

5.

Unable to verify status based on the document
provided. If this is the applicant's most recently
issued immigration document, refer the applicant to
the document issuing authority.

6.

Other

COA (KIC or KIP)

b.

Other foreign born American Indian Date
of Entry:
(mm/dd/yyyy) ►

COA

14.
15.
16.
17.

18.
19.
20.

Deferred Action for Childhood Arrivals (DACA)

Temporary Protected Status (TPS)
Deferred Action Status
VAWA Self-Petitioner
a.

Pending prima facie VAWA self-petition

b.

Approved VAWA self-petition

Withholding of Removal

USCIS is searching indices for further information

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

Expired

b.

Altered

c.

Counterfeit

USCIS Stamp

Part 3. USCIS Comments
NOTE: Only USCIS should complete this information.
1.

Unable to process request without an original consent
of disclosure statement signed by the applicant.
Resubmit request.

2.

No determination can be made because insufficient
information was submitted. Obtain a copy of the
applicant's most recently issued immigration
document. Submit a new request.

Form G-845 01/08/12 N

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