Form G-845 Supplement G-845 Supplement Verification Request Supplement

Form G-845 Supplement,
Verification Request

USCIS
Form G-845
Supplement

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

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

(mm/dd/yyyy) ►

Attn: USCIS SAVE Program Status Verification Office

Information Requested by the Registered Agency (Select all
applicable boxes)

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:

NOTE: You may only submit a completed Form G-845
Supplement with a completed Form G-845 to request
verification. You may not submit Form G-845 Supplement
alone. The information on this request concerns eligibility for
certain Federal, state, and local public benefits.

Applicant Information

6.a.

Immigration Status

6.b.

Citizenship Status

6.c.

Special Benefit Provision for Certain Victims of
Abuse

6.d.

Affidavit of Support

6.e.

USCIS to verify Cuban/Haitian entrants by filling
out Part 3.

6.f.

Form SSA-8510, Authorization for the Social Security
Administration to Obtain Personal Information, or
other agency's equivalent release form, attached. (Use
only for applicants with proceedings pending with
EOIR.)

6.g.

For SSA only: Retirement, Survivors, and Disability
Insurance (RSDI) Claim. (USCIS completes Item
Numbers 4.a. - 4.d. in Part 2.)

6.h.

Status of this applicant as of 8/22/1996 is required
(USCIS completes Item Numbers 1.a. - 1.b. in
Part 3.)

Immigration Document Number

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

Registered Agency Information

A-

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

Full Name of Agency Official
7.a. Last Name

1.c. Other Immigration Number
7.b. First Name
1.d. Name or Form Number of Document Containing the
Other Immigration Number

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

8.b. Extension Number (if applicable)
Applicant's Full Name as Shown on the Immigration
Document
2.a. Last Name

9.

Date Request Completed
(mm/dd/yyyy) ►

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

Please see next page for additional information.

Page 1 of 5

Applicant's Last Name

Applicant's First Name

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

Case Verification Number

Part 2. USCIS Responses
NOTE: Only USCIS should complete this information,
unless otherwise indicated.

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Registered Agency Comments (if any)

Upon review of these documents, information submitted, and
our records, we find the following for the applicant:
Current Immigration Status (Select all applicable boxes)
1.a.

Lawful Permanent Resident (LPR) of the United
States. (The Registered Agency must select only one
date necessary to make their benefit determination.)
Effective Date of LPR Status/Rollback
(mm/dd/yyyy) ►

Date Adjustment to LPR Approved
(mm/dd/yyyy) ►

PRIOR STATUS: If the applicant adjusted to LPR in the past
7 years from a status listed below in Item Numbers 1.b., 1.c.,
1.d., 1.g., 1.h., 1.i., or 1.j., select the appropriate prior status and
provide dates and class of admission where indicated.
1.b.

Refugee admitted to the United States under section
207 of the Immigration and Nationality Act (INA).
Date of Admission as a Refugee
(mm/dd/yyyy) ►

1.c.

Asylee under section 208 of the INA.
Date Asylum Granted
(mm/dd/yyyy) ►

1.d.

Applicant whose deportation has been withheld under
INA 243(h) (as in effect prior to April 1, 1997) or
whose removal has been withheld under
INA 241(b)(3).
Date Deportation or Removal Ordered Withheld
(mm/dd/yyyy) ►

1.e.

Applicant paroled into the United States under INA
212(d)(5) for a period of at least 1 year.
Date Parole Granted
(mm/dd/yyyy) ►
Date Parole Expires
(mm/dd/yyyy) ►

1.f.

Conditional entrant under INA 203(a)(7) prior to
April 1, 1980.
Date Status Granted
(mm/dd/yyyy) ►

Form G-845 Supplement 01/08/12 N

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Page 2 of 5

Applicant's Last Name

Applicant's First Name

Part 2. USCIS Responses (continued)
1.g.

American Indian born in Canada to whom the
provisions of INA 289 apply.

Case Verification Number

Special Benefit Provision for Certain Victims of
Abuse or Status as a Widow(er)
3.a.

Applicant obtained lawful (or conditional) permanent
resident status as the spouse, child, or widow(er) of a
U.S. citizen.

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Date Status Recognized
(mm/dd/yyyy) ►

1.h.
1.i.

Date Status Granted
(mm/dd/yyyy) ►

Cuban/Haitian entrant as defined in section 501(e) of
the Refugee Education Assistance Act of 1980.

Amerasian immigrant under section 584 of the
Foreign Operations, Export Financing, and Related
Programs Appropriations Act of 1988.

3.b.

Applicant obtained lawful (or conditional) permanent
resident status as the spouse, child, or unmarried son
or daughter of a lawful permanent resident.
Date Status Granted
(mm/dd/yyyy) ►

Date of Entry

(mm/dd/yyyy) ►

1.j.

Applicant classified as an Iraqi/Afghan special
immigrant admitted under INA 101(a)(27).
Date of Entry
(mm/dd/yyyy) ►

3.c.

Applicant did not obtain status described in Item
Number 3.a. or 3.b.

Affidavit of Support

4.a.

Applicant was not sponsored on Form I-864.

Date Status Granted
(mm/dd/yyyy) ►

Receipt Date

(mm/dd/yyyy) ►

Class of Admission (COA)

1.k.

4.b.

Applicant was sponsored on Form I-864, Affidavit of
Support, under INA 213A.

Other (Indicate Status )

Receipt Date
(mm/dd/yyyy) ►

4.c. Sponsor's Information

Date Status Granted
(mm/dd/yyyy) ►

Last Name

Class of Admission (COA) (if applicable)

First Name

Middle Name

Citizenship Status
2.a.

Social Security Number

U.S. Citizen

2.b.

Not a U.S. Citizen

Street Number
and Name

2.c.

For SSA only: Status Dates for RSDI Claims
(Registered Agency representative provides dates)

Apt.

Ste.

From

(mm/dd/yyyy) ►

City or Town

To

(mm/dd/yyyy) ►

State

Response

Flr.

ZIP Code

Province
Postal Code
Country

Form G-845 Supplement 01/08/12 N

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Applicant's Last Name

Applicant's First Name

Case Verification Number

2.b.

Part 2. USCIS Responses (continued)
4.d. Joint Sponsor's Information

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Last Name

First Name

Status Dates (Registered Agency representative
provides dates)

Middle Name

Social Security Number
Street Number
and Name

From

(mm/dd/yyyy) ►

To

(mm/dd/yyyy) ►

Response

Apt.

Ste.

Flr.

City or Town
State

2.c.

ZIP Code

Applicant paroled into the United States who has not
acquired any other status under the INA.
(Category 2A)
Status Dates (Registered Agency representative
provides dates)

Province

Postal Code
Country

4.e.

Applicant 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 April 21, 1980 (Category 1A), or a
Cuban/Haitian entrant paroled on or after October 10,
1980. (Category 1B).

2.d.

NOTE: Only USCIS should complete this information,
unless otherwise indicated. Please do not preselect
Department of Homeland Security (DHS) responses.

Upon review of these documents, information submitted, and
our records, we find the following for the applicant:

(mm/dd/yyyy) ►

To

(mm/dd/yyyy) ►

Response

Information on additional joint sponsors attached.

Part 3. USCIS Additional Responses

From

Applicant 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) ►

2.e.

Immigration status as of 8/22/1996

Applicant's asylum application was filed under INA
208 and is pending with DHS. (Category 2C)
Date Asylum Application Filed
(mm/dd/yyyy) ►

1.a. Type or print "N/A," as appropriate

2.f.

1.b. Immigration status at initial entry

Applicant's asylum application was filed under INA
208 and is pending with EOIR. (Category 2B)

NOTE: Registered Agency must attach Form SSA-8510, or
other agency's equivalent release form.

Immigration Status of Cuban/Haitian Nationals
2.a. Is the applicant a Cuban or Haitian national as indicated
by the document provided by the applicant?
Yes
No

Date Asylum Application Referred to EOIR
(mm/dd/yyyy) ►

If you answered "NO," do not process form any further.

Form G-845 Supplement 01/08/12 N

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Applicant's Last Name

Applicant's First Name

Case Verification Number

Part 3. USCIS Additional Responses (continued)

Part 4. USCIS Comments

2.g.

NOTE: Only USCIS should complete this information.

Applicant who is in removal proceedings for whom a
final, non-appealable, legally enforceable order of
removal has NOT been entered. (Category 2B.)

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Date Placed Into Proceedings
(mm/dd/yyyy) ►

2.h.

Applicant does not meet any of the categories
described above.

Removal Proceedings
3.a.

Applicant is subject to an order of removal that is
final, non-appealable, and legally enforceable.
Date Order Became Final
(mm/dd/yyyy) ►

3.b.

Applicant is subject to an order of supervision after
an order of removal.
Date of Order
(mm/dd/yyyy) ►

3.c.

Applicant is NOT subject to an order of removal that
is final, non-appealable, and legally enforceable.

Adjusted to Lawful Permanent Resident Status
4.a.

Cuban or Haitian national (or citizen) as indicated on
the document provided by the applicant who adjusted
status under:
Nicaraguan Adjustment and Central American
Relief Act (NACARA)
Haitian Refugee Immigration Fairness Act
(HRIFA)

Immigration Reform and Control Act of 1986
(IRCA)
Cuban Adjustment Act of 1966 (CAA)

Date Form I-485 Approved
(mm/dd/yyyy) ►

USCIS Stamp

Class of Admission (COA)

4.b.

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

Form G-845 Supplement 01/08/12 N

Please see next page for additional information.

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