Form G-845 Supplement - Verification Request Page 4
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5Applicant's Last Name
Applicant's First Name
Case Verification Number
2.b.
Applicant paroled into the United States as a Cuban/
Part 2. USCIS Responses (continued)
Haitian entrant (status pending) as defined in section
4.d. Joint Sponsor's Information
501(e) of the Refugee Education Assistance Act of
1980, on or after April 21, 1980 (Category 1A), or a
Last Name
Cuban/Haitian entrant paroled on or after October 10,
1980. (Category 1B).
First Name
Status Dates (Registered Agency representative
provides dates)
Middle Name
From
(mm/dd/yyyy)
Social Security Number
To
(mm/dd/yyyy)
Street Number
and Name
Response
Apt.
Ste.
Flr.
City or Town
2.c.
Applicant paroled into the United States who has not
acquired any other status under the INA.
State
ZIP Code
(Category 2A)
Status Dates (Registered Agency representative
Province
provides dates)
Postal Code
From
(mm/dd/yyyy)
Country
To
(mm/dd/yyyy)
Response
4.e.
Information on additional joint sponsors attached.
2.d.
Applicant paroled into the United States in the
Part 3. USCIS Additional Responses
custody of Federal, state, or local enforcement
NOTE: Only USCIS should complete this information,
authorities for law enforcement purposes.
unless otherwise indicated. Please do not preselect
Date of Entry
Department of Homeland Security (DHS) responses.
(mm/dd/yyyy)
Upon review of these documents, information submitted, and
our records, we find the following for the applicant:
2.e.
Applicant's asylum application was filed under INA
208 and is pending with DHS. (Category 2C)
Immigration status as of 8/22/1996
Date Asylum Application Filed
1.a.
Type or print "N/A," as appropriate
(mm/dd/yyyy)
2.f.
Applicant's asylum application was filed under INA
1.b. Immigration status at initial entry
208 and is pending with EOIR. (Category 2B)
NOTE: Registered Agency must attach Form SSA-8510, or
Immigration Status of Cuban/Haitian Nationals
other agency's equivalent release form.
2.a. Is the applicant a Cuban or Haitian national as indicated
Date Asylum Application Referred to EOIR
by the document provided by the applicant?
(mm/dd/yyyy)
Yes
No
If you answered "NO," do not process form any further.
Please see next page for additional information.
Form G-845 Supplement 05/20/15 N
Page 4 of 5
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