Form G-845 Supplement - Verification Request Page 3
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5Applicant's Last Name
Applicant's First Name
Case Verification Number
Special Benefit Provision for Certain Victims of
Part 2. USCIS Responses (continued)
Abuse or Status as a Widow(er)
1.g.
American Indian born in Canada to whom the
provisions of INA 289 apply.
3.a.
Applicant obtained lawful (or conditional) permanent
resident status as the spouse, child, or widow(er) of a
Date Status Recognized
U.S. citizen.
(mm/dd/yyyy)
Date Status Granted
1.h.
Cuban/Haitian entrant as defined in section 501(e) of
(mm/dd/yyyy)
the Refugee Education Assistance Act of 1980.
3.b.
Applicant obtained lawful (or conditional) permanent
1.i.
Amerasian immigrant under section 584 of the
resident status as the spouse, child, or unmarried son
Foreign Operations, Export Financing, and Related
or daughter of a lawful permanent resident.
Programs Appropriations Act of 1988.
Date Status Granted
Date of Entry
(mm/dd/yyyy)
(mm/dd/yyyy)
3.c.
Applicant did not obtain status described in Item
1.j.
Applicant classified as an Iraqi/Afghan special
Number 3.a. or 3.b.
immigrant admitted under INA 101(a)(27).
Date of Entry
Affidavit of Support
(mm/dd/yyyy)
4.a.
Applicant was not sponsored on Form I-864.
Date Status Granted
Receipt Date
(mm/dd/yyyy)
(mm/dd/yyyy)
Class of Admission (COA)
4.b.
Applicant was sponsored on Form I-864, Affidavit of
Support, under INA 213A.
1.k.
Other (Indicate Status)
Receipt Date
(mm/dd/yyyy)
Date Status Granted
4.c. Sponsor's Information
(mm/dd/yyyy)
Last Name
Class of Admission (COA) (if applicable)
First Name
Middle Name
Citizenship Status
Social Security Number
2.a.
U.S. Citizen
Street Number
2.b.
Not a U.S. Citizen
and Name
2.c.
For SSA only: Status Dates for RSDI Claims
Apt.
Ste.
Flr.
(Registered Agency representative provides dates)
City or Town
From
(mm/dd/yyyy)
State
ZIP Code
To
(mm/dd/yyyy)
Province
Response
Postal Code
Country
Please see next page for additional information.
Form G-845 Supplement 05/20/15 N
Page 3 of 5
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