Document Verification Request Supplement

• Legal Form Number: G-845 Supplement
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Form G-845 Supplement Edition 04/08/21 Page 1 of 5

START HERE - Type or print in black ink.►

Part 1. Information From the Registered Agency

To: U.S. Citizenship and Immigration Services (USCIS)

Attn: USCIS SAVE Program Status Verification Office

Stamp, type, or print the name, address, and ZIP Code of the

Registered Agency. (Print clearly since USCIS may use

agency address below with a No. 10 window envelope.)

From:

NOTE: You may only submit a completed Form G-845

Supplement with a completed Form G-845 to request

verification. You may not submit Form G-845 Supplement

alone. The information on this request concerns eligibility for

certain Federal, state, and local public benefits.

Immigration Document Number

1.a. Alien Registration Number (A-Number)

A-

1.b. Form I-94 Number (Arrival-Departure Record)

►

1.c. Other Immigration Number

1.d. Name or Form Number of Document Containing the

Other Immigration Number

Information Requested by the Registered Agency (Select all

applicable boxes)

6.a. Immigration Status

6.b. Citizenship Status

6.c. Special Benefit Provision for Certain Victims of

Abuse

6.d. Affidavit of Support

6.e.

Form SSA-8510, Authorization for the Social Security

Administration to Obtain Personal Information, or

other agency's equivalent release form, attached. (Use

only for applicants with proceedings pending with

EOIR.)

6.g.

Status of this applicant as of 8/22/1996 is required

(USCIS completes Item Numbers 1.a. - 1.b. in

Part 3.)

6.h.

For SSA only: Retirement, Survivors, and Disability

Insurance (RSDI) Claim. (USCIS completes Item

Numbers 4.a. - 4.d. in Part 2.)

6.f.

USCIS to verify Cuban/Haitian entrants by filling

out Part 3.

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 04/30/2024

Applicant's Full Name as Shown on the Immigration

Document

2.a. Last Name

2.b. First Name

2.c. Middle Name

5. Social Security Number

Applicant Information

3. Case Verification Number

Registered Agency Information

Full Name of Agency Official

7.a. Last Name

7.b. First Name

8.a. Daytime Telephone Number (Include Area Code)

4. Date of Birth (mm/dd/yyyy)

Please see next page for additional information.

NOTE: Only the Registered Agency should complete this

information.

8.b. Extension Number (if applicable)

9. Date Request Completed

(mm/dd/yyyy)