Form G-845 Supplement Table of Changes

TABLE OF CHANGES – FORM

Form G-845 Supplement, Document Verification Request Supplement

OMB Number: 1615-0101

12/01/2014

Reason for Revision: Form, instructions, and supplement were revised to incorporate form design and standard language updates, and operational and customer needs.

Current Section and Page Number	Current Text	Proposed Text
Title	Document Verification Request Supplement	Verification Request
New		[Page 1] START HERE – Type or print in black ink. [Page 2-6, in the header] Applicant’s Last Name Applicant’s First Name
Pages 1-2, Section A. To Be Completed by Registered Agency Only	[Page 1] To: U.S. Citizenship and Immigration Services (USCIS) Attn: USCIS SAVE Program Status Verification Office [Fillable field] From: Type or Stamp Name and Address of Registered Agency [Fillable field] 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): I-94 (Arrival-Departure Record) Number: Other immigration number (if A-Number/I-94 Number is not available): Identify document containing the other immigration number: 2. Applicant's name as shown on the immigration document (Last, First, Middle)… 8. Check the box(es) corresponding to the information your agency requests: a. Immigration Status b. Citizenship Status c. Special Benefit Provision for Certain Victims of Abuse d. Affidavit of Support 5. Name of Agency Official 6. Telephone Number (include area code) 7. Date (mm/dd/yyyy): 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. Registered Agency Comments	[Page 1] NOTE: Only the Registered Agency should complete this information. To: U.S. Citizenship and Immigration Services (USCIS) Attn: USCIS SAVE Program Status Verification Office [Drop-down box] 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: [Fillable fields] [see above] 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 Immigration Document Number 1.a. Alien Registration Number (A-Number) 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 2.a. Last Name 2.b. First Name 2.c. Middle Name 3. Case Verification Number 4. Date of Birth (mm/dd/yyyy) 5. Social Security Number Information Requested by the Registered Agency (Select all applicable boxes) 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.) Registered Agency Information Full Name of Agency Official 7.a. Last Name 7.b. First Name 8.a. Daytime Telephone Number 8.b. Extension Number (if applicable) 9. Date Request Completed (mm/dd/yyyy) [moved to be part of #5] Additional Information [Deleted] 10. Registered Agency Comments (if any)
Pages 2-4, Section B. To Be Completed by USCIS	[Page 2] 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): Effective Date of LPR status/rollback date: (mm/dd/yyyy) Date Adjustment to LPR approved: (mm/dd/yyyy) Date Form I-485 Application Approved: (mm/dd/yyyy) (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) [Page 3] e. Alien paroled into the United States under section 212(d)(5) of the INA for a period of at least 1 year. Date parole granted: (mm/dd/yyyy) Date parole expires: (mm/dd/yyyy) 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 Assistance Act of 1980. Date of parole/entry: (mm/dd/yyyy) 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. Date of entry: (mm/dd/yyyy) Date status granted: (mm/dd/yyyy) Class of Admission (COA): k. Other (indicate status): Date status granted: (mm/dd/yyyy) COA (if applicable): 2. Citizenship Status: 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. 4. Affidavit of Support: a. Alien was sponsored on Form I-864, Affidavit of Support, under section 213A of the INA. Service receipt date: (mm/dd/yyyy) Name of Sponsor: Family Name (Last Name) Given Name (First Name) Middle Name Sponsor's Social Security Number: Sponsor's Street Address: Name of Joint Sponsor: Family Name (Last Name) Given Name (First Name) Middle Name Joint Sponsor's Social Security Number: Joint Sponsor's Street Address: See attached for information on additional joint sponsor(s). b. Alien was not sponsored on Form I-864.	[Page 2] Part 2. USCIS Responses NOTE: Only USCIS should complete this information, unless otherwise indicated. 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) [Deleted] 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) [Page 3] 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) 1.g. American Indian born in Canada to whom the provisions of INA 289 apply. Date Status Recognized (mm/dd/yyyy) 1.h. Cuban/Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980. 1.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) 1.j. Applicant classified as an Iraqi/Afghan special immigrant admitted under INA 101(a)(27). Date of Entry (mm/dd/yyyy) Date Status Granted (mm/dd/yyyy) Class of Admission (COA) 1.k. Other (Indicate Status) ______________________________________ Date Status Granted (mm/dd/yyyy) Class of Admission (COA) (if applicable) Citizenship Status 2.a. U.S. Citizen 2.b. Not a U.S. Citizen 2.c. For SSA only: Status Dates for RSDI Claims (Registered Agency representative provides dates) From (mm/dd/yyyy) To (mm/dd/yyyy) Response 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. Date Status Granted (mm/dd/yyyy) 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) 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. 4.b. Applicant was sponsored on Form I-864, Affidavit of Support, under INA 213A. Receipt Date (mm/dd/yyyy) 4.c. Sponsor’s Information Last Name First Name Middle Name Social Security Number [separated into individual fields] Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Province Postal Code Country 4.d. Joint Sponsor’s Information Last Name First Name Middle Name Social Security Number [separated into individual fields] Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Province Postal Code Country 4.e. Information on additional joint sponsors attached. [moved to be 4.a. per POC]
Pages 4-5, Section C. To Be Completed by USCIS for SSA	[Page 4] 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: [Page 4] 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) Date alien placed into proceedings: (mm/dd/yyyy) 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. Date order became final: (mm/dd/yyyy) 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 IRCA of 1986 CAA of 1966 Date Form I-485 was approved: (mm/dd/yyyy) COA: b. Alien is NOT an LPR or adjusted under a different section of law.	[Page 4] Part 3. USCIS Additional Responses 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: Immigration status as of 8/22/1996 1.a. ___________________ (Type or print “N/A,” as appropriate) 1.b. Immigration status at initial entry 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 If you answered “NO, ” do not process form any further. 2.b. 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). Status Dates (Registered Agency representative provides dates) From (mm/dd/yyyy) To (mm/dd/yyyy) Response [Page 4] 2.c. 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) From (mm/dd/yyyy) To (mm/dd/yyyy) Response 2.d. 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. Applicant’s asylum application was filed under INA 208 and is pending with DHS. (Category 2C) Date Asylum Application Filed (mm/dd/yyyy) 2.f. 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. Date Asylum Application Referred to EOIR (mm/dd/yyyy) 2.g. Applicant who is in removal proceedings for whom a final, non-appealable, legally enforceable order of removal has NOT been entered. (Category 2B.) 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) Class of Admission (COA) 4.b. Applicant is NOT an LPR or adjusted under a different section of law.
Page 6, Section D. USCIS Comments	Comments:	Part 4. USCIS Comments NOTE: Only USCIS should complete this information.
		Page 5, USCIS Stamp

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