Source: https://www.templateroller.com/template/1746736/uscis-form-g-845-supplement-form-g-845-supplement-verification-request.html
Timestamp: 2020-07-10 20:25:50
Document Index: 471467696

Matched Legal Cases: ['art 1', 'art 3', 'art 2', 'art 2', 'art 2', 'art 3', 'art 3', 'art 4']

USCIS Form G-845 Download Fillable PDF or Fill Online Verification Request | Templateroller
What Is USCIS Form G-845?
This is a legal form that was released by the U.S. Department of Homeland Security - Citizenship and Immigration Services on May 29, 2018 and used country-wide. Check the official instructions before completing and submitting the form.
Released on May 29, 2018;
Download a fillable version of USCIS Form G-845 by clicking the link below or browse more documents and templates provided by the U.S. Department of Homeland Security - Citizenship and Immigration Services.
Download USCIS Form G-845 "Verification Request"
Form G-845 Supplement,
OMB No. 1615-0101
Part 1. Information From the Registered Agency
NOTE: Only the Registered Agency should complete this
Attn: USCIS SAVE Program Status Verification Office
Information Requested by the Registered Agency (Select all
applicable boxes)
Stamp, type, or print the name, address, and ZIP Code of the
Registered Agency. (Print clearly since USCIS may use
Special Benefit Provision for Certain Victims of
agency address below with a No. 10 window envelope.)
USCIS to verify Cuban/Haitian entrants by filling
out Part 3.
Form SSA-8510, Authorization for the Social Security
Administration to Obtain Personal Information, or
other agency's equivalent release form, attached. (Use
NOTE: You may only submit a completed Form G-845
only for applicants with proceedings pending with
Supplement with a completed Form G-845 to request
EOIR.)
verification. You may not submit Form G-845 Supplement
alone. The information on this request concerns eligibility for
For SSA only: Retirement, Survivors, and Disability
certain Federal, state, and local public benefits.
Insurance (RSDI) Claim. (USCIS completes Item
Numbers 4.a. - 4.d. in Part 2.)
Status of this applicant as of 8/22/1996 is required
(USCIS completes Item Numbers 1.a. - 1.b. in
Immigration Document Number
1.a. Alien Registration Number (A-Number)
Registered Agency Information
1.b. Form I-94 Number (Arrival-Departure Record)
Full Name of Agency Official
7.a. Last Name
1.c. Other Immigration Number
7.b. First Name
8.a. Daytime Telephone Number (Include Area Code)
1.d. Name or Form Number of Document Containing the
Other Immigration Number
8.b. Extension Number (if applicable)
Applicant's Full Name as Shown on the Immigration
2.a. Last Name
2.b. First Name
Please see next page for additional information.
Form G-845 Supplement 05/29/18
Part 2. USCIS Responses
NOTE: Only USCIS should complete this information,
Upon review of these documents, information submitted, and
Registered Agency Comments (if any)
our records, we find the following for the applicant:
Current Immigration Status (Select all applicable boxes)
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
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.
Refugee admitted to the United States under section
207 of the Immigration and Nationality Act (INA).
Date of Admission as a Refugee
Date Asylum Granted
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
Applicant paroled into the United States under INA
212(d)(5) for a period of at least 1 year.
Date Parole Granted
Date Parole Expires
Conditional entrant under INA 203(a)(7) prior to
Part 2. USCIS Responses (continued)
Abuse or Status as a Widow(er)
American Indian born in Canada to whom the
provisions of INA 289 apply.
Applicant obtained lawful (or conditional) permanent
resident status as the spouse, child, or widow(er) of a
Date Status Recognized
Cuban/Haitian entrant as defined in section 501(e) of
the Refugee Education Assistance Act of 1980.
Amerasian immigrant under section 584 of the
resident status as the spouse, child, or unmarried son
or daughter of a lawful permanent resident.
Programs Appropriations Act of 1988.
Applicant did not obtain status described in Item
Applicant classified as an Iraqi/Afghan special
Number 3.a. or 3.b.
immigrant admitted under INA 101(a)(27).
Applicant was not sponsored on Form I-864.
Class of Admission (COA)
Applicant was sponsored on Form I-864, Affidavit of
Support, under INA 213A.
Other (Indicate Status)
4.c. Sponsor's Information
Class of Admission (COA) (if applicable)
For SSA only: Status Dates for RSDI Claims
(Registered Agency representative provides dates)
Applicant paroled into the United States as a Cuban/
Haitian entrant (status pending) as defined in section
4.d. Joint Sponsor's Information
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)
Applicant paroled into the United States who has not
acquired any other status under the INA.
Information on additional joint sponsors attached.
Applicant paroled into the United States in the
Part 3. USCIS Additional Responses
custody of Federal, state, or local enforcement
authorities for law enforcement purposes.
unless otherwise indicated. Please do not preselect
Department of Homeland Security (DHS) responses.
Applicant's asylum application was filed under INA
208 and is pending with DHS. (Category 2C)
Immigration status as of 8/22/1996
Date Asylum Application Filed
Type or print "N/A," as appropriate
1.b. Immigration status at initial entry
208 and is pending with EOIR. (Category 2B)
NOTE: Registered Agency must attach Form SSA-8510, or
Immigration Status of Cuban/Haitian Nationals
other agency's equivalent release form.
2.a. Is the applicant a Cuban or Haitian national as indicated
Date Asylum Application Referred to EOIR
by the document provided by the applicant?
If you answered "NO," do not process form any further.
Part 3. USCIS Additional Responses (continued)
Part 4. USCIS Comments
NOTE: Only USCIS should complete this information.
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
Applicant does not meet any of the categories
Applicant is subject to an order of removal that is
final, non-appealable, and legally enforceable.
Date Order Became Final
Applicant is subject to an order of supervision after
an order of removal.
Applicant is NOT subject to an order of removal that
is final, non-appealable, and legally enforceable.
Adjusted to Lawful Permanent Resident Status
Cuban or Haitian national (or citizen) as indicated on
the document provided by the applicant who adjusted
status under:
Relief Act (NACARA)
Cuban Adjustment Act of 1966 (CAA)
Date Form I-485 Approved
Applicant is NOT an LPR or adjusted under a
different section of law.
USCIS Form I-800A Supplement 3 "Request for Action on Approved Form I-800a"
USCIS Form I-684W "Request for Exemption for Intending Immigrant's Affidavit of Support"
Instructions for USCIS Form G-845 "Verification Request"
Instructions for USCIS Form G-1450 "Authorization for Credit Card Transactions"
DSHS Form 14-462 "Epilepsy Verification Request" - Washington