Fillable Printable G 845Supinstr
Fillable Printable G 845Supinstr
G 845Supinstr
Form G-845 Supplement Instructions 05/20/15 N
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Instructions for Form G-845 Supplement,
Verification Request
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form G-845
Supplement
OMB No. 1615-0101
Expires 05/31/2018
What Is the Purpose of This Form?
An agency that is registered with the U.S. Citizenship and Immigration Services' (USCIS) Systematic Alien Verification
for Entitlements (SAVE) Program may file this form with Form G-845, Verification Request, to request more detailed
information on immigration status, citizenship, and sponsorship.
Who May File This Form?
Any agency that has executed a Memorandum of Agreement with the USCIS SAVE Program may file this form if the
agency needs additional information found on the Form G-845 Supplement that is not found on the Form G-845 to
administer certain benefits. If you are not sure whether you can use the Supplement, please check with the SAVE
Program.
General Instructions
For each applicant, you must submit a completed Form G-845 Supplement with a completed Form G-845 to request
verification. You may notsubmit the Form G-845 Supplement alone. The information on this request concerns
eligibility for certain Federal, state, and local public benefits.
If you do not follow the instructions, USCIS' SAVE Program may return this form without a verification response, which
may delay processing.
Copies. Submit copies (front and back) of the applicant's most recently issued immigration documentation. In addition to
the most recently issued immigration documentation, you may also submit any relevant documents bearing on the
applicant's immigration status or admission. Ensure that copies are legible and made from original documents.
How To Fill Out Form G-845 Supplement
1.Type or print legibly in black ink.
2.If you need extra space to complete any item within this request, attach a separate sheet of paper; type or print the
applicant's last name, first name, and Case Verification Number at the top of each sheet; and indicate the Page
Number, Part Number, and Item Number to which the information refers.
3.
For each applicant, you must complete a separate Form G-845 and Form G-845 Supplement and include copies of
documents only for that individual. If a family unit applies for a benefit, submit a separate Form G-845 and Form G-845
Supplement for each family member.
USCIS provides forms free of charge through the USCIS Web site. In order to view, print, or fill out our forms, you
should use the latest version of Adobe Reader, which you can download for free at //get.adobe.com/reader/
.
Specific Instructions
Part 1. Information From the Registered Agency
1.
NOTE: Only the Registered Agency should complete the information in this part of the request.
In the "To" section, stamp, type, or print the mailing address of the Registered Agency's assigned Status Verification
Office; you can find this address atwww.uscis.gov/save.
If you are filling the form out manually, type or print the applicant's last name, first name and Case Verification
Number at the top of each page. For example: Smith, John, 123456789123456.
Form G-845 Supplement Instructions 05/20/15 N
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NOTE: You MUST enter a complete return address into the "From" portion of the request. You also MUST
complete ALL items in Part 1. (SAVE may use this portion of the form to display your address in a number 10
window envelope.)
3.
Complete Item Numbers 1. - 10.
Item Numbers 1a. - 1.d. Immigration Document Numbers. Enter the Alien Registration Number (A-Number) or
Form I-94 Number in the space provided or both the A-Number and Form I-94 Number if both numbers are listed on the
provided document. The A-Number is the letter "A" followed by a 7, 8, or 9-digit number. The Form I-94 Number is
found on Form I-94, Arrival-Departure Record, and is 11 digits. If you received a paper Form I-94, check the front and
back of the Form I-94. If the A-Number appears, record that number when requesting information because the A-Number
refers to the most integral record available.
Enter any other immigration numbers, such as the applicant's foreign passport number or Certificate of Citizenship
document number, in the data collection box entitled "Other Immigration Number." Provide the name or form numbers of
the documents that contain these immigration numbers in the next data collection box. These numbers can be included with
the A-Number and Form I-94 Number. If it is a foreign passport, include the name of the country of issuance.
Item Numbers 2.a. - 2.c. Full Name. Enter the applicant's last name, first name, and middle name exactly as printed on
the immigration document.
Item Number 3. Case Verification Number. Enter the15-digit case verification number if a query was initiated in the
SAVE online system. If the SAVE online system was not used, leave this blank.
Item Number 4. Date of Birth. Enter the applicant's date of birth in the mm/dd/yyyy format.
Item Numbers 6.a. - 6.h. Information Requested by the Registered Agency. Select all applicable boxes to indicate
the verification requested.
Item Numbers 7.a. - 8.b. Registered Agency Information. Enter the submitting official's first and last name, title,
daytime telephone number, and extension number in the spaces provided.
Item Number 9. Date Request Completed. Enter the date that the submitting official completed the Form G-845
Supplement.
Item Number 10. Registered Agency Comments (if any). The Registered Agency may enter additional information
about the immigration verification request. Use this box for providing additional information or comments such as:
1.
Aliases;
2.
Date of entry into the United States;
3.
Previous receipt numbers; and
4.
Special requests from the Registered Agency.
Part 2.USCIS Responses
Only USCIS should complete the information in this part of the request, except as indicated below.
Item Number 2.c. Status Dates for RSDI Claims. If the Social Security Administration (SSA) is requesting additional
verification for an SSA Retirement, Survivors, and Disability Insurance (RSDI) claim, the SSA representative must
provide the period of time for the applicant's status related to the RSDI claim.
Item Number 5. U.S. Social Security Number. Enter the applicant's U.S. Social Security Number, if applicable.
2.In the "From" section, stamp, type, or print the Registered Agency's name, and mailing address with ZIP Code.
Form G-845 Supplement Instructions 05/20/15 N
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Item Numbers 2.b. - 2.c. Status Dates for Cuban/Haitian Nationals.If the Registered Agency is requesting verification
for an applicant paroled into the United States as a Cuban/Haitian entrant with status pending (Categories 1A and 1B) or
who did not acquire any other status under the INA (Category 2A), the Registered Agency's representative must provide the
period of time for the applicant's status related to the verification request.
NOTE: If the Registered Agency is requesting verification for an applicant paroled into the United States as a Cuban/
Haitian entrant with an EOIR-pending asylum application (Item Number 2.f.), the Registered Agency's representative
must attach Form SSA-8510, Authorization for the Social Security Administration to Obtain Personal Information, or
other agency's equivalent release form, with this request.
Part 4.USCIS Comments
Only USCIS should complete the information in this part of the request.
Processing Information
Upon receipt, the SAVE Program Status Verification Office will review the form for completeness, including submission
of any attached documents. If the Form G-845 Supplement is not completely filled out, USCIS will return the form
to you with no verification response.
Also, if the Form G-845 Supplement is submitted without a completed Form G-845 and a copy of the applicant's most
recently issued immigration documentation, USCIS will return it to you with no verification response.
USCIS Forms and Information
To ensure you are using the latest version of this form, visit the USCIS Web site at www.uscis.gov where you can obtain
the latest USCIS forms and immigration-related information. If you do not have Internet access, you may order USCIS
forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by calling the
USCIS National Customer Service Center at 1-800-375-5283. For TTY (deaf or hard of hearing) call: 1-800-767-1833.
USCIS Privacy Act Statement
USCIS AUTHORITIES: The information requested on this form, and the associated evidence, is collected under the
Immigration and Nationality Act, sections 101, et seq.
PURPOSE: The primary purpose for providing the information on this form is to verify the status of the applicant.
DISCLOSURE: Failure to provide the requested information, and any requested evidence, may delay a response to your
request.
ROUTINE USES: DHS may share the information you provide on this form with other Federal, state, local, and foreign
government agencies and authorized organizations under approved routine uses described in the associated published
system of records notices [DHS/USCIS-004 - Systematic Alien Verification for Entitlements Program System of Records,
September 21, 2011, 76 FR 58525], which you can find at www.dhs.gov/privacy
. DHS may also make the information
available, as appropriate, for law enforcement purposes or in the interest of national security.
Part 3.USCIS Additional Responses
Only USCIS should complete the information in this part of the request, except as indicated below. Please do not
preselect Department of Homeland Security (DHS) responses.
Form G-845 Supplement Instructions 05/20/15 N
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Paperwork Reduction Act
An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of
information, unless it displays a currently valid OMB control number. The public reporting burden for this collection of
information is estimated at 5 minutes per response, including the time for reviewing instructions and completing and
submitting the request. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory
Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave NW, Washington, DC 20529-2140;
OMB No. 1615-0101. Do not mail your completed Form G-845 Supplement to this address.
