Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 24
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32IMMIGRATION STATUSES AND DOCUMENT TYPES
Question 9a on the application asks noncitizens about their immigration status and about the type or types of immigration
documents they have to support their immigration status. Please refer to the following lists to fill out Question 9a.
If you need further help, details can be found online at https://
Eligible Immigration Statuses
• Granted Temporary Protected Status
Immigration Document Types
(TPS) or applicant for TPS with
In the “Immigration Status” section of
In the “Immigration Document Type”
employment authorization
Question 9a, write in any status that
section of Question 9a, write in any
applies to you or members of your
• Granted employment authorization
document type you or members of your
household. You may write in more than
under 8 CFR 274a(12)(c)
household have. You may list more than
one status.
one immigration document type.
• Family unity beneficiaries
• Amerasian
• Reentry Permit (I-327)
• Deferred enforced departure
• Granted asylum
• Permanent Resident Card (“green card,”
• Deferred Action Status except for
I-551)
• Cuban Haitian entrant
Deferred Action for Childhood Arrivals
Process (DACA)
• Refugee Travel Document (I-571)
• Deportation withheld
• Granted an administrative stay of
• Employment Authorization Card (I-766)
• Native American born in Canada or non-
removal under 8 CFR 241
US territories
• Machine Readable Immigrant Visa (with
• Approved visa petition with a pending
temporary 1-551 language)
• Refugee
application for adjustment of status
• Temporary I-551 stamp (on passport or
• Victim of severe trafficking or his or her
• Applicant for asylum or for withholding of
I-94, I-94A
spouse, child, sibling, or parent
removal with employment authorization
• Arrival Departure Record (I-94,
• Iraqi special immigrant
• Applicant (for at least 180 days) under
I-94A) issued by U.S. Citizenship and
• Afghan special immigrant
age 14 for asylum or for withholding of
Immigration Services
• Conditional entrant granted before 1980
removal
• Arrival Departure Record in unexpired
• Veteran or active duty member
• Granted withholding of removal under
foreign passport (I-94)
of military or his or her spouse or
the Convention Against Torture
• Unexpired foreign passport
dependent
• Applicant for Special Immigrant Juvenile
• Certificate of Eligibility for Nonimmigrant
• Lawful permanent resident
(SIJ) status
(F1) Student Status (I-20)
• Granted parole for at least one year
• Applicant or granted status under
• Certificate of Eligibility for Exchange
• Battered spouse or child (or his or her
Deferred Action for Childhood Arrivals
Visitor (J1) Status (DS2019)
parent or child)
(DACA)
• Notice of Action (I-797)/Other-with Alien
• Nonimmigrant status (visa)
• I have a document but do not have any
Number
• Granted parole for less than one year
status listed above (Person Residing
• Notice of Action (I-797)/Other-with I-94
• Granted temporary resident status
Under Color of Law, PRUCOL)
Number
Page 22
ACA-3 (Rev. 07/17)
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