This form reflects information that may be relevant to eligibility for Federal, State, and local public benefits under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Pub. L. 104-193.
Number of Pages :
Form 6; Instructions 2.
Edition Date :
01/08/12. Previous edtions not accepted.
Where to File :
Submit this form in conjunction with Form G-845: it cannot be used alone. To obtain the mailing address for your Form G-845 or G-845 Supplement click on the "Direct Filing Addresses for Form G-845, and G-845 Supplement" link located in the related links section of this page.
Filing Fee :
Special Instructions :
This form should not be used alone, but only in conjunction with Form G-845 to request verification.