Form G-845 Supplement - Verification Request Page 2
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5Applicant's Last Name
Applicant's First Name
Case Verification Number
Part 1. Information From the Registered Agency
Part 2. USCIS Responses
(continued)
NOTE: Only USCIS should complete this information,
unless otherwise indicated.
Additional Information
Upon review of these documents, information submitted, and
10.
Registered Agency Comments (if any)
our records, we find the following for the applicant:
Current Immigration Status (Select all applicable boxes)
1.a.
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
(mm/dd/yyyy)
Date Adjustment to LPR Approved
(mm/dd/yyyy)
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).
Date of Admission as a Refugee
(mm/dd/yyyy)
1.c.
Asylee under section 208 of the INA.
Date Asylum Granted
(mm/dd/yyyy)
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).
Date Deportation or Removal Ordered Withheld
(mm/dd/yyyy)
1.e.
Applicant paroled into the United States under INA
212(d)(5) for a period of at least 1 year.
Date Parole Granted
(mm/dd/yyyy)
Date Parole Expires
(mm/dd/yyyy)
1.f.
Conditional entrant under INA 203(a)(7) prior to
April 1, 1980.
Date Status Granted
(mm/dd/yyyy)
Please see next page for additional information.
Form G-845 Supplement 05/20/15 N
Page 2 of 5
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