Form G-845 - Verification Request
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3Verification Request
USCIS
Form G-845
Department of Homeland Security
OMB No. 1615-0101
U.S. Citizenship and Immigration Services
Expires: 05/31/2018
►
START HERE - Type or print in black ink.
3.
Case Verification Number
Part 1. Information From the Registered Agency
NOTE: Only the Registered Agency should complete this
information.
4.
Date of Birth
(mm/dd/yyyy)
To: U.S. Citizenship and Immigration Services (USCIS)
5.
Social Security Number
Attn: USCIS SAVE Program Status Verification Office
►
6.
Student and Exchange Visitor Information System
(SEVIS) Number
7.
Citizenship or Nationality
Stamp, type, or print the name, address, and ZIP Code of the
Documents Attached (Select all that apply)
Registered Agency. (Print clearly since USCIS may use
agency address below with a No. 10 window envelope.)
8.a.
Photocopy of most recently issued immigration
document attached. Ensure copies are legible and
From:
made from an original document. If the immigration
document is printed on both sides, attach a copy of
the front and back.
8.b.
Other Information Attached (Specify Documents)
Benefits Sought
Applicant Information
9.a.
Background Check
Immigration Document Number
9.b.
Driver's License/ID
1.a.
Alien Registration Number (A-Number)
►
9.c.
Education Grant/Loan/Work Study
A-
9.d.
Employment Authorization
1.b. Form I-94 Number (Arrival-Departure Record)
►
9.e.
Food Stamps
9.f.
Housing Assistance
1.c. Other Immigration Number
9.g.
Medicaid/Medical Assistance
9.h.
Social Security Number
1.d. Name or Form Number of Document Containing the
Other Immigration Number
9.i.
SSI or RSDI
9.j.
TANF
9.k.
Unemployment Insurance
Applicant's Full Name as Shown on the Immigration
Document
9.l.
Other (Specify)
2.a. Last Name
2.b. First Name
2.c. Middle Name
Form G-845 05/20/15 N
Page 1 of 3
Please see next page for additional information.
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