Fillable Form G-845 Supplement, Document: Verification Request Supplement (Visa Pro)

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Form G-845 Supplement, Document: Verification Request Supplement (Visa Pro)

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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
OMB No. 1615-0101; Expires 01/31/2015
To: U.S. Citizenship and Immigration Services (USCIS)
Attn.: USCIS SAVE Program Status Verification Office
From: Type or Stamp Name and Address of Registered Agency
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
2. Applicant's name as shown on the immigration document
(Last, First, Middle)
Other immigration number (if A-Number/I-94 Number is
number:
Identify document containing the other immigration
not available):
Form G-845 Supplement 01/08/12 N
3. Date of Birth (mm/dd/yyyy):
6. Telephone Number (include area code)
5. Name of Agency Official
7. Date (mm/dd/yyyy):
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
d. Affidavit of Support
For SSA Use Only:
USCIS to verify Cuban/Haitians Entrants by filling out
SSA-8510 attached (To be used only for applicants
RSDI Claim: USCIS complete Items B. 4(a) and (b).
Status of this applicant as of 8/22/1996 is required
4. Social Security Number:
USCIS Stamp
Abuse
I-94 (Arrival-Departure Record) Number:
Alien Registration Number (A-Number):
Section C.
with proceedings pending with EOIR).
USCIS to complete Item C. 1.
►
A-
►
( )
-
►
►
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:
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):
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.)
(mm/dd/yyyy)
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)
Form G-845 Supplement 01/08/12 N Page 2
1. Current Immigration Status (Check all that apply):
Effective Date of LPR status/rollback date:
Section A. To Be Completed by Registered Agency Only (continued)
Registered Agency Comments
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)
c. Asylee under section 208 of the INA. Date asylum granted:
(mm/dd/yyyy)
Form G-845 Supplement 01/08/12 N Page 3
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: Date parole expires:
(mm/dd/yyyy) (mm/dd/yyyy)
f. Conditional entrant under section 203(a)(7) of the INA prior to April 1, 1980.
g. American Indian born in Canada to whom the provisions of section 289 of the INA apply.
h. Alien paroled into the United States as a Cuban/Haitian entrant, as defined in section 501(e) of the Refugee Education
i. Amerasian immigrant under section 584 of the Foreign Operations, Export Financing, and Related Programs
Date status recognized:
Assistance Act of 1980. Date of parole/entry:
Appropriations Act of 1988. Date of entry:
(mm/dd/yyyy)
(mm/dd/yyyy)
Date status granted:
(mm/dd/yyyy)
j. Alien classified as an Iraqi/Afghan special immigrant admitted under section 101(a)(27) of the INA.
Date of entry: Date status granted:
Class of Admission (COA):
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
k. Other (indicate status):
Date status granted: COA (if applicable):(mm/dd/yyyy)
2. Citizenship Status:
U.S. Citizen.
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.
b. Alien obtained lawful permanent (or conditional) resident status as the spouse, child, or unmarried son or daughter of a
lawful permanent resident alien.
c. Alien did not obtain status as described in 3(a) or 3(b) above.
Date status granted:
Date status granted:
(mm/dd/yyyy)
(mm/dd/yyyy)
Only for SSA RSDI Claims, SSA to fill in requested dates.
(mm/dd/yyyy)
Response:
(mm/dd/yyyy)Status from: To:
SSA to fill in requested dates Status from:
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).
Response:
(mm/dd/yyyy) to:
(mm/dd/yyyy)
Form G-845 Supplement 01/08/12 N Page 4
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:
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
(mm/dd/yyyy)
4. Affidavit of Support:
a. Alien was sponsored on Form I-864, Affidavit of Support, under section 213A of the INA.
Service receipt date:
b. Alien was not sponsored on Form I-864.
See attached for information on additional joint
sponsor(s).
Name of Sponsor:
Sponsor's Social Security Number:
Sponsor's Street Address:
Name of Joint Sponsor:
Joint Sponsor's Social Security Number:
Joint Sponsor's Street Address:
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:
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Family Name
(Last Name)
Given Name
(First Name)
Middle Name
Section C. To Be Completed by USCIS for SSA (Continued)
Date Form I-485 was approved:
NACARA IRCA of 1986HRIFA CAA of 1966
(mm/dd/yyyy)
4. Adjusted to Lawful Permanent Resident
a. Cuban or Haitian entrant who adjusted to LPR status under:
b. Alien is NOT an LPR or adjusted under a different section of law.
Form G-845 Supplement 01/08/12 N Page 5
COA:
a. Alien is subject to an order of removal which is final, non-appealable, and legally enforceable.
b. Alien is subject to an order of supervision after an order of removal.
c. Alien is NOT subject to an order of removal which is final, non-appealable, and legally enforceable.
3. Removal Proceedings:
Date order became final:
(mm/dd/yyyy)Date of order:
(mm/dd/yyyy)
g. Person does not meet any of the categories described above.
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:
Date asylum application filed:
(mm/dd/yyyy)
Date asylum application referred to EOIR:
e.1. Alien whose asylum application filed under section 208 of the INA is pending with DHS. (Category 2C)
e.2. Alien whose asylum application filed under section 208 of the INA is pending with EOIR. (Category 2B)
(mm/dd/yyyy)
(mm/dd/yyyy)
(SSA attach Form SSA-8510)
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)
(mm/dd/yyyy)(mm/dd/yyyy) to:
Response:
SSA to fill in requested dates Status from:
c. Alien paroled into the United States who has not acquired any other status under the INA. (Category 2A)
Section D. USCIS Comments
Comments:
Form G-845 Supplement 01/08/12 N Page 6
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Form G-845 Supplement, Document: Verification Request Supplement (Visa Pro)

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Completed 29 July 2020

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