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Document Verification Request Supplement G-845 - Official Federal Forms
| Document Verification Request Supplement Form. This is a national form and can be used in US Citizenship And Immigration Services . |
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OMB No. 1615-0101; Expires 01/31/2015 Department of Homeland Security U.S. Citizenship and Immigration Services Form G-845 Supplement, Document Verification Request Supplement Section A. To Be Completed by Registered Agency Only To: U.S. Citizenship and Immigration Services (USCIS) Attn.: USCIS SAVE Program Status Verification Office 5. Name of Agency Official 6. Telephone Number (include area code) ( 7. Date (mm/dd/yyyy): From: Type or Stamp Name and Address of Registered Agency ) - 8. Check the box(es) corresponding to the information your agency requests: a. Immigration Status b. Citizenship Status 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): c. Special Benefit Provision for Certain Victims of Abuse d. Affidavit of Support 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. AI-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) USCIS Stamp 3. Date of Birth (mm/dd/yyyy): 4. Social Security Number: Form G-845 Supplement 01/08/12 N American LegalNet, Inc. www.FormsWorkFlow.com Section A. To Be Completed by Registered Agency Only (continued) Registered Agency Comments Section B. To Be Completed by USCIS 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: Date Adjustment to LPR approved: Date Form I-485 Application Approved: (mm/dd/yyyy) (mm/dd/yyyy) (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) (mm/dd/yyyy) c. Asylee under section 208 of the INA. Date asylum granted: 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) Form G-845 Supplement 01/08/12 N Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Section B. To Be Completed by USCIS (continued) 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: Class of Admission (COA): k. Other (indicate status): Date status granted: 2. Citizenship Status: U.S. Citizen. (mm/dd/yyyy) COA (if applicable): (mm/dd/yyyy) Date status granted: (mm/dd/yyyy) Only for SSA RSDI Claims, SSA to fill in requested dates. Status from: 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) (mm/dd/yyyy) To: (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. Form G-845 Supplement 01/08/12 N Page 3 American LegalNet, Inc. www.FormsWorkFlow.com 4. Affidavit of Support: a. Alien was sponsored on Form I-864, Affidavit of Support, under section 213A of the INA. Service receipt date: Name of Sponsor: Family Name (Last Name) Given Name (First Name) Middle Name Sponsor's Social Security Number: (mm/dd/yyyy) Name of Joint Sponsor: Family Name (Last Name) Given Name (First Name) Middle Name Joint Sponsor's Social Security Number: Sponsor's Street Address: Joint Sponsor's Street Address: b. Alien was not sponsored on Form I-864. See attached for information on additional joint sponsor(s). Section C. To Be Completed by USCIS for SSA 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: 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 COA: 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: Response: (mm/dd/yyyy) to: (mm/dd/yyyy) Form G-845 Supplement 01/08/12 N Page 4 American LegalNet, Inc. www.FormsWorkFlow.com Section C. To Be Completed by USCIS for SSA (Continue
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