Form G-845 - Supplement, Document Verification Request Supplement - Department Of Homeland Security Page 2

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Section A. To Be Completed by Registered Agency Only (continued)
Registered Agency Comments
Section B. To Be Completed by USCIS
USCIS Responses:
After review of the documents and/or information submitted, and/or our records, we find that the document
appears valid and relates to a/an:
1. Current Immigration Status (Check all that apply):
a. Lawful Permanent Resident (LPR) alien of the United States. Requesting agency must choose the date that they need to
make their benefit determination (check only one):
(mm/dd/yyyy)
Effective Date of LPR status/rollback date:
(mm/dd/yyyy)
Date Adjustment to LPR approved:
(mm/dd/yyyy)
Date Form I-485 Application Approved:
(If alien adjusted to LPR status from status in the past 7 years, complete b, c, d, g, h, i, or j below.)
b. Refugee admitted to the United States under section 207 of the Immigration and Nationality Act (INA).
(mm/dd/yyyy)
Date of admission as refugee:
c. Asylee under section 208 of the INA. Date asylum granted:
(mm/dd/yyyy)
d. Alien whose deportation has been withheld under section 243(h) of the INA (as in effect prior to April 1, 1997) or whose
removal has been withheld under section 241(b)(3).
(mm/dd/yyyy)
Date deportation or removal ordered withheld:
Form G-845 Supplement 01/08/12 N Page 2

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