OMB No. 1615-0101; Expires 01/31/2015
Form G-845 Supplement, Document
Department of Homeland Security
Verification Request Supplement
U.S. Citizenship and Immigration Services
Section A. To Be Completed by Registered Agency Only
To: U.S. Citizenship and Immigration Services (USCIS)
5. Name of Agency Official
Attn.: USCIS SAVE Program Status Verification Office
6. Telephone Number (include area code)
(
)
-
►
7. Date (mm/dd/yyyy):
From: Type or Stamp Name and Address of Registered Agency
8. Check the box(es) corresponding to the information your
agency requests:
a. Immigration Status
b. Citizenship Status
c. Special Benefit Provision for Certain Victims of
Print clearly since USCIS may use above agency address
Abuse
with a No. 10 window envelope.
d. Affidavit of Support
NOTE: A completed Form G-845 Supplement must be used
with a completed Form G-845 to request verification - it may
not be used alone. The information on this form concerns
For SSA Use Only:
eligibility for Federal, State, and local public benefits under
the Personal Responsibility and Work Opportunity
USCIS to verify Cuban/Haitians Entrants by filling out
Reconciliation Act of 1996, P.L. 104-193.
Section C.
1. Immigration Document Number
SSA-8510 attached (To be used only for applicants
with proceedings pending with EOIR).
Alien Registration Number (A-Number):
►
A-
RSDI Claim: USCIS complete Items B. 4(a) and (b).
Status of this applicant as of 8/22/1996 is required
I-94 (Arrival-Departure Record) Number:
USCIS to complete Item C. 1.
►
Other immigration number (if A-Number/I-94 Number is
not available):
Identify document containing the other immigration
USCIS Stamp
number:
2. Applicant's name as shown on the immigration document
(Last, First, Middle)
►
3. Date of Birth (mm/dd/yyyy):
4. Social Security Number:
Form G-845 Supplement 01/08/12 N
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