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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL APPENDIX I NON-CITIZEN DOCUMENTATION MATRIX Division of Welfare and Supportive Services Medical Assistance Manual 23 Jan 05 MTL 01/23

U.S. Immigrations Category U.S. Immigrations Documents Document Comments

• 1-730 letter • United States Refugee Travel Document

• The I-730 Approval Letter may be used as proof of refugee status for • Visa 93 or V-93 on the I-94 Arrival/departure card derivatives

• May be accompanied by the words “section 207”, individual is the spouse or • “Memo of Agreement” with Migration and Refugee Services minor child of a previously admitted refugee Asylees • I-94 Arrival/departure record referencing 208 of the • Notations may include references to employment authorization, indefinity  Acceptable documents for asylees whose INA status, and the requirement to obtain permission before leaving the United status was granted under 208 of the INA

States. • AS-1 admission code on the I-94 • Approved asylee principal • AS-2 admission code on the I-94 • Approved spouse of an asylee principal • AS-3 admission code on the I-94 • Approved child of an asylee principal • DHS Form I-571 • United States Refugee Travel Document • I-766 Employment Authorization Document with the • NONE code A05

• Order of an Immigration Judge Granting Asylum • An order of an Immigration Judge will serve as proof of asylee status if DHS under 208 of the INA has waived the right to appeal the case. • Asylum Approval Letter from a USCIS Asylum Office • Letter will note that the individual has been granted asylum pursuant to 208

of the INA and may include information concerning date of asylum, refugee

and asylee relative petition, work authorization and the refugee travel

document. • Written decision from the Board of Immigration

• NONE Appeals (BIA).

• I-730 Approval Letter • Visa 92 or V-92 on the I-94 Arrival/departure record • The I-730 Approval Letter may be used as proof of asylee status for • “Memo of Agreement” with Migration and Refugee derivatives Services • May be accompanied by the words “section 208”; individual is the spouse or minor child of a Cuban & Haitian Entrants I • An I-94 Arrival/departure record with a stamp • I-94 may refer to 212(d)(5)  Acceptable documents for Cuban & Haitian showing parole at any time as a “Cuban/Haitian

entrants, in accordance with the requirements Entrant (Status Pending)”

in 45 CFR 401.2 • CH6 adjustment code on the I-551 • “Memo of Agreement” with Migration and Refugee • Even after the Cuban/Haitian Entrant (Status Pending) becomes a Services permanent resident, he/she is still considered to be a Cuban and Haitian entrant Cuban & Haitian Entrants II • An I-94 Arrival/departure record showing parole into • I-94 may be to 212(d)(5)  A national of Cuba or Haiti who was paroled the United States on or after April 12, 1980

into the United States and has not acquired • A Cuban or Haitian passports with a 212(d)(5) any other status under the INA & with respect stamp dated on or after October 10, 1980 • NONE to whom a final, non-appealable, and legally • An I-94 Arrival/departure record showing parole into

enforceable order of removal, deportation or the United States • I-94 may refer to 212(d)(5), humanitarian or public interest parole exclusion has not been entered • I-766 Employment Authorization Document with the • NONE code A04

• I-766 Employment Authorization Document with the • NONE code C11 • “Memo of Agreement” with Migration and Refugee Services