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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2012 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 7 3

Paroled into the U.S. • Form I-94 or I-94A indicating “parole” or “PIP” or “212(d)(5),” or other language indicating parole status; • Form I-688B or I-766 EAD coded 274a.12(a)(4), 274a.12(c)(11), A4, or C11; or • Any verification from the INS, DHS, or other authoritative document. NOTE: If subsequently adjusted to LPR status, may have I-551 card (for Lautenberg parolees, these may be coded LA). Granted Temporary Protected Status (TPS) • Form I-688B or I-766 EAD coded 274a.12(a)(12) or A12; • Form I-797 Notice of Action showing grant of TPS status; or • Any verification from the INS, DHS, or other authoritative document. Applicant for TPS, with employment authorization • Receipt or notice showing filing or pending status of Form I-821 (Application for Temporary Protected Status); • Form I-688B or I-766 EAD coded 274a.12(c)(19) or C19; or • Any verification from the INS, DHS, or other authoritative document. Granted Deferred Enforced Departure (DED) • Form I-688B or I-766 EAD coded 274a.12(a)(11) or A11; or • Any verification from the INS, DHS, or other authoritative document. Granted Deferred Action Status • Form I-797 Notice of Action or other form showing approval of deferred action status; • Form I-688B or I-766 EAD coded 274a.12(c)(14) or C14; or • Any verification from the INS, DHS, or other authoritative document. Applicant for Special Immigrant Juvenile Status • Form I-797 Notice of Action Special Immigrant Juvenile Approval Notice; • Form I-797 Welcome Notice/Approval of I-485, “Other Basis of Adjustment SL6”; • I-551 coded “SL6”; or • Any verification from the INS, DHS, or other authoritative document. “Qualified” Domestic Violence Survivor Must have a pending petition for an immigrant visa, either filed by a spouse or a self-petition under the Violence Against Women Act (VAWA), or an application for suspension of deportation or cancellation of removal. The petition or application must either be approved or, if not yet approved, must present a prima facie case. • Receipt or other proof of filing I-130 (visa petition) under immediate relative (IR) or 2nd family preference (P-2) showing status as a spouse or child; • Form I-360 (application to qualify as abused spouse, child, or parent under the VAWA); • Form I-797 Notice of Action referencing pending I-130 or I-360 or finding establishment of a prima facie case; • Receipt or other proof of filing I-485Application for Adjustment of Status on basis of an immediate relative or family 2nd preference petition or VAWA application; • Any documents indicating a pending suspension of deportation or cancellation of removal case, including a receipt from an immigration court indicating filing of Form EOIR-40 (Application for Suspension of Deportation) or EOIR-42 (Application for Cancellation of Removal); Form I-688B or I-766 EAD coded 274a.12(a)(10) or A10 (applicant for suspension of deportation) or 274a.12(c)(14) or C14 (individual granted deferred action status); or • Any verification from the INS, DHS, or other authoritative document.