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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

category SI6 or SQ6

• DHS Form I-551 (“green card”) with an IV (immigrant visa) code for • Principal Applicant Iraqi or Afghan Special Immigrant category SI7 or SQ7 Status in the United States

• Spouse of Principal Applicant Iraqi or Afghan Special • DHS form I-551 (“green card”) with an IV (immigrant visa) code for Principal Applicant Adjusting Status in the United category SI8 or SQ8 States

• Unmarried Child Under 21 Years of Age of Iraqi or • Same as above Afghan Special Immigrant • Principal Applicant Adjusting Status in the United States. • “Memo of Agreement” with Migration and Refugee Services Unaccompanied Refugee Minors  Unaccompanied Minor who holds one of the following • In addition to unaccompanied minors in the above categories,  Acceptable Documents for the ORR statuses: the following are eligible for the ORR Unaccompanied Refugee Unaccompanied Refugee Minors (URM)  Refugee, Asylee, Cuban/Haitian Entrant, Victim of Minors (URM) Program: Program Trafficking with an Eligibility Letter from OTIP, LPR  Unaccompanied Minor with Special Immigrant Juvenile who has held one of those statuses, Amerasian, Status (SIJS) under 8 U.S.C 1101(a)(2)(J), who was in the Iraqi/Afghan Special Immigrant custody of the Secretary of Health and Human Services at  Minor with Special Immigrant Juvenile Status (SIJS) the time the dependency order was granted for such child  Unaccompanied Minor who holds U status or U visa or was receiving service pursuant to section 501(a) of the  “Memo of Agreement” with Migration and Refugee Refugee Education Assistance Act of 1980 (8 U.S.C. 1522 Services note) at the time such dependency order was granted.  Unaccompanied Minor who has been granted U status per section 101(a)(15)(U) of the Immigration and Nationality Act (8 U.S.C 1101 (a)(15)(U). • 1-797 Notice of Action indicating SIJS status, i.e. evidence of approved I-360, or evidence of approved I-360 and approved I-485 OR • Visa indicating SIJS status with SL class of admission code OR • I-551 indicating SIJS status with SL class of admission code AND • Evidence that at the time a Dependency Order was issued, was either: in the custody of the ORR Unaccompanied Children’s (UC) Program OR • Receiving federal benefits or services as a Cuban/Haitian Entrant • I-797 Notice of Action indicating U status • U Visa • I-94 Arrival/departure record showing admission U status Victims of Human Trafficking • Victims of a Severe Form of Trafficking in Persons • Certification Letter, Eligibility Letter, or Interim Assistance Letter from  Acceptable documents for Victims of a

ACF Office (Administration for Children & Families) on Trafficking in Severe Form of Trafficking in Persons

Persons (OTP) • Call the trafficking verification line at (866)401-5510 to confirm the

validity of the Certification Letter

• Certification and Eligibility Letters DO NOT expire

• Derivative T status: T-2, T-3, T-4, T-5 or T-6 (D • The date of eligibility for benefits and services is the Notice Date on • Family member of Victim of a Severe Form of the I-797, Notice of Action of approval of that individual’s Derivative Trafficking in Persons: T status. • Family member already in United States on date T • Persons with derivative T status do not receive and are not required status granted to present a Certification Letter or Eligibility Letter to demonstrate eligibility for benefits or services