Form G-845 Supplement - Verification Request
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5Form G-845 Supplement,
USCIS
Verification Request
Form G-845
Supplement
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
Information Requested by the Registered Agency (Select all
applicable boxes)
6.a.
Immigration Status
6.b.
Citizenship Status
Stamp, type, or print the name, address, and ZIP Code of the
Registered Agency. (Print clearly since USCIS may use
6.c.
Special Benefit Provision for Certain Victims of
agency address below with a No. 10 window envelope.)
Abuse
6.d.
Affidavit of Support
From:
6.e.
USCIS to verify Cuban/Haitian entrants by filling
out Part 3.
6.f.
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
6.g.
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.)
Applicant Information
6.h.
Status of this applicant as of 8/22/1996 is required
(USCIS completes Item Numbers 1.a. - 1.b. in
Immigration Document Number
Part 3.)
1.a. Alien Registration Number (A-Number)
A-
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
Document
9.
Date Request Completed
2.a. Last Name
(mm/dd/yyyy)
2.b. First Name
2.c. Middle Name
Please see next page for additional information.
Form G-845 Supplement 05/20/15 N
Page 1 of 5
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