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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 4

Victim of Trafficking • Certification from U.S. Dept. of Health and Human Services (HHS) Office of Refugee Resettlement (ORR); • ORR eligibility letter (if under 18); • Certification status verified through HHS Trafficking Verification Line 202-401-5510 or 866-401-5510 ; • I-914 (T status application); • I-766 coded (a)(16); • Form I-797 approval notice for “CP” (continued presence); • Form I-797 indicating approval of T-1 Status; • Bona fide case determination on a T status application; or • Form I-797 “Extension of T or U Nonimmigrant Status”; • I-512 authorization for parole, indicating T-1 status; • I-551 coded ST6; or • Any verification from HHS, INS, DHS, or other authoritative document. Derivative Beneficiary of Trafficking Survivor • Proof of approved I-914A petition (derivative T status); • I-94 or passport stamped T-2, T-3, T-4, or T-5; • Form I-797 Notice of Action indicating approval of T-2, T-3, T-4 or T-5 status; • I-766 EAD coded (c)(25); • Form I-797 “Extension of T or U Nonimmigrant Status”; • I-512 authorization for parole, indicating T-2, T-3, T-4 or T-5 status; • I-551 card coded ST7, ST8, ST9, or ST0; or • Any verification from HHS, INS, DHS, or other authoritative document. Nonimmigrant • Form I-94 or I-94A Arrival/Departure Record or passport indicating admission to U.S. with nonimmigrant visa; • Receipt for Form I-102 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document; • I-797 approving application to extend/change nonimmigrant status; • I-797 approving application for S, T, U, or V nonimmigrant status; • Form I-688B or I-766 EAD or other INS/DHS document indicating nonimmigrant status; or • Any verification from the INS, DHS, or other authoritative document. Citizen of Micronesia, the Marshall Islands, and Palau • Form I-94 or passport noted as “CFA/RMI” or “CFA/FSM” or “CFA/PAL”; • Form I-766 coded (a)(8); or • Any verification from the INS, DHS, or other authoritative document. Lawful Temporary Resident • Form I-688 Temporary Resident Card; • Form I-688A EAD; • Form I-688B or I-766 EAD coded 274a.12(a)(2) or A2; or with other evidence indicating eligibility under INA §§210 or 245A ; • Form I-698 Application to Adjust from Temporary to Permanent Residence under INA § 245A; or • Any verification from the INS, DHS, or other authoritative document.