Form G-845 Supplement Instructions Table of Changes

TABLE OF CHANGES – INSTRUCTIONS

Form G-845 Supplement, Verification Request

OMB Number: 1615-0101

12/09/2014

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

Current Location	Current Text	Proposed Text
Page 1, Top of Page	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.	[Deleted]
Page 1,	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, Verification Request, to request more detailed information on immigration status, citizenship, and sponsorship.	Page 1, What Is the Purpose of This Form? An agency that is registered with the U.S. Citizenship and Immigration Services’ (USCIS) Systematic Alien Verification for Entitlements (SAVE) Program may file this form with Form G-845, Verification Request, to request more detailed information on immigration status, citizenship, and sponsorship.
Page 1,	Who May File This Form? Any agency that has executed a Memorandum of Agreement with the USCIS SAVE Program.	Page 1, Who May File This Form? Any agency that has executed a Memorandum of Agreement with the USCIS SAVE Program may file this form if the agency needs additional information found on the Form G-845 Supplement that is not found on the Form G-845 to administer certain benefits. If you are not sure whether you can use the Supplement, please check with the SAVE Program.
Page 1, 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.)	Page 1, General Instructions For each applicant, you must submit a completed Form G-845 Supplement with a completed Form G-845 to request verification. You may not submit the Form G-845 Supplement alone. The information on this request concerns eligibility for certain Federal, state, and local public benefits. If you do not follow the instructions, USCIS’ SAVE Program may return this form without a verification response, which may delay processing. For each applicant, you must complete a separate Form G-845 and Form G-845 Supplement and 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. [Deleted] [new] USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you should use the latest version of Adobe Reader, which you can download for free at http://get.adobe.com/reader/. Copies. Submit copies (front and back) of the applicant's most recently issued immigration documentation. In addition to the most recently issued immigration documentation, you may also submit any relevant documents bearing on the applicant’s immigration status or admission. Ensure that copies are legible and made from original documents. [Deleted] How To Fill Out Form G-845 Supplement Type or print legibly in black ink. If you need extra space to complete any item within this request, attach a separate sheet of paper; type or print the applicant’s last name, first name, and Case Verification Number at the top of each sheet; and indicate the Page Number, Part Number, and Item Number to which the information refers. If you are filling the form out manually, type or print the applicant’s last name, first name and Case Verification Number at the top of each page. For example: Smith, John, 123456789123456.
Page 1-2, General Instructions	[Page 1] 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. Complete items numbered 1 through 8 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. 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. 8. Check the corresponding box for the verification requested. 5 - 6. Enter the name of the agency official and telephone number. 7. Enter the date the Form G-845 Supplement is completed. Registered Agency Comments Box (Optional): Agency may enter additional information about the immigration verification request. 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.	[Page 1] Specific Instructions [new header] Part 1. Information From the Registered Agency NOTE: Only the Registered Agency should complete the information in this part of the request. 1. In the "To" section, stamp, type, or print the mailing address of the Registered Agency's assigned Status Verification Office; you can find this address at www.uscis.gov/save. 2. In the "From" section, stamp, type, or print the Registered Agency’s name, and mailing address with ZIP Code. NOTE: You MUST enter a complete return address into the "From" portion of the request. You also MUST complete ALL items in Part 1. (SAVE may use this portion of the form to display your address in a number 10 window envelope.) 3. Complete Item Numbers 1. - 10. Item Numbers 1a. – 1.d. Immigration Document Numbers. Enter the Alien Registration Number (A-Number) or Form I-94 Number in the space provided or both the A-Number and Form I-94 Number if both numbers are listed on the provided document. The A-Number is the letter "A" followed by a 7, 8, or 9-digit number. The Form I-94 Number is found on Form I-94, Arrival-Departure Record, and is 11 digits. If you received a paper Form I-94, check the front and back of the Form I-94. If the A-Number appears, record that number when requesting information because the A-Number refers to the most integral record available. Enter any other immigration numbers such as the applicant's foreign passport number or Certificate of Citizenship document number instead of the Form I-94 number in the data collection box entitled "Other Immigration Number." Provide the name or form numbers of the documents that contain these immigration numbers in the next data collection box. These numbers can be included with the A-Number and Form I-94 Number. If it is a foreign passport, include the name of the country of issuance. Item Numbers 2.a. – 2.c. Full Name. Enter the applicant's last name, first name, and middle name exactly as printed on the immigration document. Item Number 3. Case Verification Number. Enter the 15-digit case verification number if a query was initiated in the SAVE online system. If the SAVE online system was not used, leave this blank. Item Number 4. Date of Birth. Enter the applicant's date of birth in the mm/dd/yyyy format. Item Number 5. U.S. Social Security Number. Enter the applicant's U.S. Social Security Number, if applicable. [See Item Number 3 above] Item Numbers 6a – 6.h. Information Requested by the Registered Agency. Select all applicable boxes to indicate the verification requested. Item Numbers 7.a. – 8.b. Registered Agency Information. Enter the submitting official’s first and last name, title, daytime telephone number, and extension number in the spaces provided. Item Number 9. Date Request Completed. Enter the date that the submitting official completed the Form G-845 Supplement. Item Number 10. Registered Agency Comments (if any). The Registered Agency may enter additional information about the immigration verification request. Use this box for providing additional information or comments such as: 1. Aliases; 2. Date of entry into the United States; 3. Previous receipt numbers; and 4. Special requests from the Registered Agency. Part 2. USCIS Responses Only USCIS should complete the information in this part of the request, except as indicated below. Item Number 2.c. Status Dates for RSDI Claims. If the Social Security Administration (SSA) is requesting additional verification for an SSA Retirement, Survivors, and Disability Insurance (RSDI) claim, the SSA representative must provide the period of time for the applicant’s status related to the RSDI claim. Part 3. USCIS Additional Responses Only USCIS should complete the information in this part of the request, except as indicated below. Please do not preselect Department of Homeland Security (DHS) responses. Item Numbers 2.b. – 2.c. Status Dates for Cuban /Haitian Nationals. If the Registered Agency is requesting verification for an applicant paroled into the United States as a Cuban/Haitian entrant with status pending (Categories 1A and 1B) or who did not acquire any other status under the INA (Category 2A), the Registered Agency’s representative must provide the period of time for the applicant’s status related to the verification request. NOTE: If the Registered Agency is requesting verification for an applicant paroled into the United States as a Cuban/Haitian entrant with an EOIR-pending asylum application (Item Number 2.f.), the Registered Agency’s representative must attach Form SSA-8510, Authorization for the Social Security Administration to Obtain Personal Information, or other agency’s equivalent release form, with this request. Part 4. USCIS Comments Only USCIS should complete the information in this part of the request.
Page 2, 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. 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.	Page 3, Processing Information Upon receipt, the SAVE Program Status Verification Office will review the form for completeness, including submission of any attached documents. If the Form G-845 Supplement is not completely filled out, USCIS will return the form to you with no verification response. Also, if the Form G-845 Supplement is submitted without a completed Form G-845 and a copy of the applicant's most recently issued immigration documentation, USCIS will return it to you with no verification response.
		Page 3, [new] USCIS Forms and Information To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order USCIS forms by calling our toll-free number at 1-800-870-3676.  You may also obtain forms and information by calling the USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
Page 3, 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.	Page 3, USCIS AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the Immigration and Nationality Act, sections 101, et seq. PURPOSE: The primary purpose for providing the information on this form is to verify the status of the applicant. DISCLOSURE: Failure to provide the requested information, and any requested evidence, may delay a response to your request. ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local, and foreign government agencies and authorized organizations under approved routine uses described in the associated published system of records notices [DHS/USCIS-004 - Systematic Alien Verification for Entitlements Program System of Records, September 21, 2011, 76 FR 58525], which you can find at www.dhs.gov/privacy. DHS may also make the information available, as appropriate, for law enforcement purposes or in the interest of national security.
Page 3, 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. Do not mail your verification request to this address.	Page 3, 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 request. 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 Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140; OMB No. 1615-0101. Do not mail your completed Form G-845 Supplement to this address.

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