Form G-845 05/29/18 Page 1 of 3 Verification Request Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form G-845 OMB No. 1615-0101 Expires 05/31/2021 Part 1. Information From the Registered Agency Immigration Document Number Applicant Information1.a.START HERE - Type or print in black ink.NOTE: Only the Registered Agency should complete this information.To: U.S. Citizenship and Immigration Services (USCIS)Attn: USCIS SAVE Program Status Verification OfficeStamp, 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.)Alien Registration Number (A-Number)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 6.Student and Exchange Visitor Information System(SEVIS) Number3.Case Verification NumberDocuments Attached (Select all that apply)8.a. Photocopy of most recently issued immigration document attached. Ensure copies are legible and made from an original document. If the immigration document is printed on both sides, attach a copy of the front and back.8.b. Other Information Attached (Specify Documents) Benefits Sought9.a. Background Check9.b. Driver's License/ID 9.c. Education Grant/Loan/Work Study9.d. Employment Authorization 9.e. Food Stamps 9.f. Housing Assistance 4.Date of Birth (mm/dd/yyyy) 5.Social Security Number From: Applicant's Full Name as Shown on the Immigration Document2.a.Last Name 9.g. Medicaid/Medical Assistance 9.h. Social Security Number 9.i. SSI or RSDI 9.j. TANF9.k. Unemployment Insurance9.l. Other (Specify) 7.Citizenship or Nationality2.c.Middle Name 2.b.First Name Please see next page for additional information. A- Form G-845 05/29/18 Page 2 of 3 Part 1. Information From the Registered Agency (continued) 12.Title of Agency Official 13.a.Daytime Telephone Number (Include Area Code) 13.b.Extension Number (if applicable) 14.Fax Number (if any) (Include Area Code)15.Date Request Completed(mm/dd/yyyy) 16.Registered Agency Comments (if any)7.Applicant was paroled into the United States undersection 212 of the Immigration and Nationality Act(INA). 8.Conditional entrant of the United States No Expiration Date (Indefinite) Parole Granted Date (mm/dd/yyyy) Parole Expiration Date (mm/dd/yyyy)9.Nonimmigrant (Specify type or class and expirationdate) 10.U.S. Citizen Type or Class Expiration Date (mm/dd/yyyy)5.Applicant has an application pending for thefollowing USCIS benefit: 6.Applicant was granted asylum or refugee status inthe United States Applicant's Last Name Applicant's First Name3.Applicant is employment authorized in the UnitedStates as indicated: No Expiration Date (Indefinite) Expiration Date (mm/dd/yyyy) Previous Employment Authorization Dates Start Date (mm/dd/yyyy)End Date (mm/dd/yyyy) 4.Applicant is not employment authorized in theUnited States Registered Agency Information 11.a.Last Name 11.b.First Name Full Name of Agency Official Case Verification Number 10.Registered Agency Case Number Please see next page for additional information. Part 2. USCIS ResponsesNOTE: Only USCIS should complete this information.Upon review of these documents, information submitted, and our records, we find the following for the applicant:1.Lawful Permanent Resident of the United States2.Conditional Permanent Resident of the UnitedStates Form G-845 05/29/18 Page 3 of 3 6.Other Applicant's Last Name Applicant's First Name14.Deferred Action for Childhood Arrivals (DACA) 15.Temporary Protected Status (TPS) 16. VAWA Self-Petitioner17.Deferred Action Status 18.Withholding of Removal Part 2. USCIS Responses (continued)19.USCIS is searching indices for further information 20.This document is not valid because it appears to be:(Select all that apply) Expired Altereda.b. Counterfeitc. 13.Mexican Born Member of the Texas or OklahomaBand of Kickapoo Indians I-872 Issuance Date:a. (mm/dd/yyyy)COA (KIC or KIP) Other foreign born American Indian Date of Entry:b. (mm/dd/yyyy)COA 5.Unable to verify status based on the documentprovided. If this is the applicant's most recentlyissued immigration document, refer the applicant tothe document issuing authority. USCIS Stamp 4.Copy provided of applicant's immigration documentis illegible. Submit a new request with legibledocuments. 3.No determination can be made without seeing bothsides of the applicant's immigration document.Attach copies (front and back) of the applicant's mostrecently issued immigration document and submit anew request. American Indian born in Canada to whom theprovisions of INA 289 apply.11.Cuban/Haitian entrant of the United States 12. (mm/dd/yyyy)Date Status RecognizedCase Verification Number Pending prima facie VAWA self-petition Approved VAWA self-petitiona.b. Part 3. USCIS Comments NOTE: Only USCIS should complete this information.1.Unable to process request without an original consentof disclosure statement signed by the applicant.Resubmit request. 2.No determination can be made because insufficientinformation was submitted. Obtain a copy of theapplicant's most recently issued immigrationdocument. Submit a new request.