Form G-845 - Supplement, Document Verification Request Supplement - Department Of Homeland Security Page 4

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4. Affidavit of Support:
a. Alien was sponsored on Form I-864, Affidavit of Support, under section 213A of the INA.
(mm/dd/yyyy)
Service receipt date:
Name of Sponsor:
Name of Joint Sponsor:
Family Name
Family Name
(Last Name)
(Last Name)
Given Name
Given Name
(First Name)
(First Name)
Middle Name
Middle Name
Sponsor's Social Security Number:
Joint Sponsor's Social Security Number:
Sponsor's Street Address:
Joint Sponsor's Street Address:
b. Alien was not sponsored on Form I-864.
See attached for information on additional joint
sponsor(s).
Section C. To Be Completed by USCIS for SSA
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:
1. Immigration Status of alien as of 8/22/1996:
(enter status as of this date or "not applicable" as appropriate)
Status at Entry:
COA:
2. Immigration Status of Cuban/Haitian nationals:
a. Is the Alien a Cuban or Haitian national? (Select only one)
No If not C/H, STOP
Yes
b. Alien paroled into the United States as a Cuban/Haitian entrant (status pending) as defined in section 501 (e) of the Refugee
Education Assistance Act of 1980, on or after 04/21/1980 (Category 1A), or a Cuban Haitian entrant paroled on or after
October 10, 1980 (Category 1B).
(mm/dd/yyyy)
SSA to fill in requested dates Status from:
(mm/dd/yyyy) to:
Response:
Form G-845 Supplement 01/08/12 N Page 4

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