Fillable G-845sup Form G-845 Supplement, Verification Request

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G-845sup Form G-845 Supplement, Verification Request

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U.S. Citizenship and Immigration Services (USCIS) is an office of the U.S. Branch of Homeland Security (DHS) that oversees the nation's naturalization and migration framework. It is a successor to the Immigration and Naturalization Service (INS), which was disintegrated by the Homeland Security Act of 2002 and supplanted by three segments inside the DHS: USCIS, Immigration and Customs Enforcement (ICE), and Customs and Border Protection (CBP).

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Form G-845 Supplement 05/29/18 Page 1 of 5
START HERE - Type or print in black ink.►
Part 1. Information From the Registered Agency
To: U.S. Citizenship and Immigration Services (USCIS)
Attn: USCIS SAVE Program Status Verification Office
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.
Immigration Document Number
1.a. Alien Registration Number (A-Number)
A-
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
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.
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.
Status of this applicant as of 8/22/1996 is required
(USCIS completes Item Numbers 1.a. - 1.b. in
Part 3.)
6.h.
For SSA only: Retirement, Survivors, and Disability
Insurance (RSDI) Claim. (USCIS completes Item
Numbers 4.a. - 4.d. in Part 2.)
6.f.
USCIS to verify Cuban/Haitian entrants by filling
out Part 3.
Form G-845 Supplement,
Verification Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form G-845
Supplement
OMB No. 1615-0101
Expires 05/31/2021
Applicant's Full Name as Shown on the Immigration
Document
2.a. Last Name
2.b. First Name
2.c.
Middle Name
5. Social Security Number
Applicant Information
3. Case Verification Number
Registered Agency Information
Full Name of Agency Official
7.a. Last Name
7.b. First Name
8.a. Daytime Telephone Number (Include Area Code)
4. Date of Birth (mm/dd/yyyy)
Please see next page for additional information.
NOTE: Only the Registered Agency should complete this
information.
8.b. Extension Number (if applicable)
9.
Date Request Completed
(mm/dd/yyyy)
Form G-845 Supplement 05/29/18 Page 2 of 5
Applicant's Last Name Applicant's First Name
Part 1. Information From the Registered Agency
(continued)
Additional Information
10. Registered Agency Comments (if any)
Case Verification Number
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:
1.a. Lawful Permanent Resident (LPR) of the United
States. (The Registered Agency must select only one
date necessary to make their benefit determination.)
(mm/dd/yyyy)
Current Immigration Status (Select all applicable boxes)
Effective Date of LPR Status/Rollback
(mm/dd/yyyy)
Date Adjustment to LPR Approved
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).
(mm/dd/yyyy)
Date of Admission as a Refugee
1.c. Asylee under section 208 of the INA.
(mm/dd/yyyy)
Date Asylum Granted
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).
(mm/dd/yyyy)
Date Deportation or Removal Ordered Withheld
1.e. Applicant paroled into the United States under INA
212(d)(5) for a period of at least 1 year.
(mm/dd/yyyy)
Date Parole Granted
(mm/dd/yyyy)
Date Parole Expires
Conditional entrant under INA 203(a)(7) prior to
April 1, 1980.
1.f.
(mm/dd/yyyy)
Date Status Granted
Please see next page for additional information.
Form G-845 Supplement 05/29/18 Page 3 of 5
Applicant's Last Name Applicant's First Name
Case Verification Number
1.g. American Indian born in Canada to whom the
provisions of INA 289 apply.
(mm/dd/yyyy)
Date Status Recognized
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.
(mm/dd/yyyy)
Date of Entry
1.j. Applicant classified as an Iraqi/Afghan special
immigrant admitted under INA 101(a)(27).
(mm/dd/yyyy)
Date of Entry
(mm/dd/yyyy)
Date Status Granted
Class of Admission (COA)
Part 2. USCIS Responses (continued)
1.k. Other (Indicate Status)
(mm/dd/yyyy)
Date Status Granted
Class of Admission (COA) (if applicable)
Citizenship Status
2.a. U.S. Citizen
2.c. For SSA only: Status Dates for RSDI Claims
(Registered Agency representative provides dates)
(mm/dd/yyyy)From
(mm/dd/yyyy)To
Response
2.b. Not a U.S. Citizen
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.
(mm/dd/yyyy)
Date Status Granted
3.b. Applicant obtained lawful (or conditional) permanent
resident status as the spouse, child, or unmarried son
or daughter of a lawful permanent resident.
(mm/dd/yyyy)
Date Status Granted
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.
(mm/dd/yyyy)
Receipt Date
4.b. Applicant was sponsored on Form I-864, Affidavit of
Support, under INA 213A.
(mm/dd/yyyy)
Receipt Date
4.c. Sponsor's Information
Last Name
First Name
Middle Name
Social Security Number
Please see next page for additional information.
Street Number
and Name
City or Town
State ZIP Code
Postal Code
Apt.
Flr.Ste.
Province
Country
(USPS ZIP Code Lookup)
Form G-845 Supplement 05/29/18 Page 4 of 5
Part 2. USCIS Responses (continued)
Applicant's Last Name Applicant's First Name
Case Verification Number
4.d. Joint Sponsor's Information
Last Name
First Name
Middle Name
Social Security Number
Street Number
and Name
City or Town
State ZIP Code
Apt.
Flr.Ste.
Province
Country
Postal Code
4.e. Information on additional joint sponsors attached.
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)
(mm/dd/yyyy)From
(mm/dd/yyyy)To
Response
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)
(mm/dd/yyyy)From
(mm/dd/yyyy)To
Response
2.d. Applicant paroled into the United States in the
custody of Federal, state, or local enforcement
authorities for law enforcement purposes.
(mm/dd/yyyy)
Date of Entry
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: 2.e. Applicant's asylum application was filed under INA
208 and is pending with DHS. (Category 2C)
(mm/dd/yyyy)
Date Asylum Application Filed
Please see next page for additional information.
1.a.
Immigration status as of 8/22/1996
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.f. Applicant's asylum application was filed under INA
208 and is pending with EOIR. (Category 2B)
(mm/dd/yyyy)
Date Asylum Application Referred to EOIR
NOTE: Registered Agency must attach Form SSA-8510, or
other agency's equivalent release form.
Form G-845 Supplement 05/29/18 Page 5 of 5
Applicant's Last Name Applicant's First Name
Case Verification Number
Part 3. USCIS Additional Responses (continued)
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.)
(mm/dd/yyyy)
Date Placed Into Proceedings
2.h. Applicant does not meet any of the categories
described above.
(mm/dd/yyyy)
Date Order Became Final
Removal Proceedings
3.a. Applicant is subject to an order of removal that is
final, non-appealable, and legally enforceable.
(mm/dd/yyyy)
Date of Order
3.b. Applicant is subject to an order of supervision after
an order of removal.
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)
Part 4. USCIS Comments
NOTE: Only USCIS should complete this information.
USCIS Stamp
(mm/dd/yyyy)
Date Form I-485 Approved
Class of Admission (COA)
4.b. Applicant is NOT an LPR or adjusted under a
different section of law.
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G-845sup Form G-845 Supplement, Verification Request

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Completed 6 November 2019

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