7001 Citizenship and Immigration Services OMBudsman

Case Problem Submission Worksheet (CIS Ombudsman DHS Form 7001)
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OMB No. 1601-0004;  Exp. 09/20/2011

Citizenship and Immigration Services Ombudsman - Form DHS-7001
Introduction
The Office of Citizenship and Immigration Services Ombudsman is an independent office within the Department of Homeland Security and is not part of
U.S. Citizenship and Immigration Services (USCIS). The Ombudsman’s Office is here to help individuals and employers who have not been able to
resolve a problem directly with USCIS.
Before you Submit a Case Problem to the Citizenship and Immigration Services Ombudsman
USCIS may be able to provide the answer to many frequently asked questions such as:
What type of form do I file?
Where do I file a particular form?
How do I notify USCIS of a change of address?
How do I find out about processing times at various USCIS Service Centers or Field Offices?
How do I receive an update on my case status?
Before asking the Ombudsman’s Office for help with your application or petition, you should first try to resolve the problem with USCIS by using the
following methods:
Obtain information about your case status at My Case Status at www.uscis.gov.
Contact the National Customer Service Center (NCSC) for assistance at 1-800-375-5283.
Make an appointment to speak directly with a USCIS Immigration Services Officer at a local office through the InfoPass system. Appointments
may be made online at infopass.uscis.gov.
While there is no time limit to complete this form, this form cannot be saved and completed at a later time. Your session will time out after
20 minutes of inactivity.
--NOTICE-Please note that while the Ombudsman’s Office provides impartial and independent recommendations to USCIS on how to resolve problems, the
Ombudsman’s Office does not have the statutory authority to make or change USCIS decisions.
Privacy Act Requirements
All information submitted to the Office of the Citizenship and Immigration Services Ombudsman is collected and protected under the provisions of the
Privacy Act. By submitting this information to the Ombudsman’s Office, you are consenting to our review of your information and allowing us to contact
USCIS on your behalf.
Paperwork Reduction Act
The public reporting burden to complete this information collection is estimated at one hour per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collected information. An agency may
not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid Office of Management
and Budget (OMB) control number and expiration date. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to the DHS Office of the Citizenship & Immigration Services Ombudsman, [E-mail:
[email protected]; Mailing Address: Citizenship and Immigration Services Ombudsman, U.S. Department of Homeland Security, Mail Stop 1225,
Washington, D.C. 20528-1225], ATTN: PRA OMB 1601-0004.
Name and Address ( Section 1 and 2 )
1. Name: The person encountering difficulties with USCIS (applicant/beneficiary/petitioner).
Prefix:

* First Name:

Middle Name:

* Last Name:

(Jr., Sr., III, etc.):

2. Contact information: The contact information for the person encountering difficulties with USCIS (applicant/beneficiary/petitioner).
* Street Address:

Apartment/Suite:

* State/Province:

* ZIP/Postal Code:

E-Mail Address:
Please send any future correspondence to me via e-mail and not by US Mail.

* City:
* Country:

UNITED
STATES
OF AMERICA
UNITED
STATES
OF AMERICA

Phone Number:

Fax Number:

(with area code)

(with area code)

Validate

Identification Information ( Section 3, 4, 5, and 6 )
3. Date of Birth: The person encountering difficulties with USCIS (applicant/beneficiary/petitioner).
* Birth Month:  

* Birth Day:  

4. Country of Citizenship and Birth:
Country of Citizenship:
Country of Birth:

UNITED
STATES
OF AMERICA
UNITED
STATES
OF AMERICA

UNITED
STATES
OF AMERICA
UNITED
STATES
OF AMERICA

5. A-number: The A-number appears in the following format: A123-456-789.
Alien Number:

A

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* Birth Year:  

Case Problem Submission Worksheet (CIS Ombudsman DHS Form 7001)

6. Person preparing this form: Please indicate who is submitting this case problem.
Important: If you are the beneficiary of a pending petition, and you are not a lawful permanent resident or U.S. citizen, the petitioner must provide consent to the release of information
relating to your case.
* I am:

The person encountering difficulties with USCIS (applicant/beneficiary/petitioner);
An organization on behalf of an individual;
An attorney/accredited representative;
Other (please explain fully).
Validate

Application/Petition Information ( Section 7, 8, and 9 )
7. Applications/Petitions filed: List all applications or petitions currently filed with USCIS relating to your case problem.
Dates received
by USCIS:

USCIS Forms:

8. Receipt Numbers:
List all available
USCIS Receipt
Numbers.

Add More ...

9. Immigration benefit sought:
As a Nonimmigrant (extension of a stay for a visitor visa, change of status to student, fiance, temporary worker, Temporary Protected Status (TPS), etc.);
As an Immigrant (Adjustment of Status; often called "Green Card" application);
For Citizenship or Naturalization;
For Asylum or Refugee Status;
For Interim Benefits (Work Permit, Travel Document, etc.);
For a Waiver (Waiver of Grounds of Inadmissibility, Permission to Reapply, etc.);
Other (Action on an Approved Petition, Replacement Permanent Resident Card, etc.):
Validate

Case Description ( Section 10 and 11 )
10. Source of case problem: Check all that apply and provide a description in Number 11 below.
I am facing or am about to face an immediate adverse action or impact, an emergency or any other type of significant hardship, caused by an action,
inaction, or delay in processing by USCIS; 
I am facing a problem that could not be resolved through the normal processes provided for by the USCIS; 
I am experiencing processing delays with a case that are beyond USCIS anticipated processing times;
I am incurring or am about to incur significant and unusual costs (including fees for professional representation that are not normally incurred); 
I have tried to resolve this problem directly with USCIS and have not received a response or resolution within the anticipated time frame; 
Other (please specify): 
11. * Description of your case problem:

Validate

Prior Actions Taken to Remedy the Problem ( Section 12 )
12. Prior actions taken to remedy the problem: Check all that apply:
Contacted an attorney/accredited representative regarding this issue for assistance (if represented); 
Visited USCIS My Case Status at www.uscis.gov. 
Contacted the National Customer Service Center (NCSC) for information and/or assistance regarding this case at its toll-free number 1-800-375-5283. 

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Case Problem Submission Worksheet (CIS Ombudsman DHS Form 7001)

Contacted the following government department/agency for assistance:
Contacted the following congressional representative for assistance:
Other:
Validate

Attorney/Accredited Representative Information ( Section 13 )
13. Attorney/Accredited Representative: Please complete this section if you are an attorney, organization, or accredited representative submitting this case
problem on another’s behalf.
* First Name:

Middle Name:

* Last Name:

Organization:
* Street Address:

Apartment/Suite:

* State/Province:

* Country:

* ZIP/Postal Code:

Email Address:

* City:
UNITED
STATES
OF AMERICA
UNITED
STATES
OF AMERICA

* Phone Number:

Fax Number:

   (with area code)

(with area code)

I am an attorney and a member in good standing of the highest court of the following State, territory, insular possession, or District of Columbia and am not
under a court or administrative agency order suspending, enjoining, restraining, disbarring, or otherwise restricting me in practicing law.
I am an accredited representative of the following named religious, charitable, social service or similar organization established in the United States and
recognized by the Board of Immigration Appeals pursuant to 8 CFR 292.1.
I am submitting a copy of USCIS Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this form.
Other (Explain):
Validate

Supporting Documentation
Supporting Documentation: Additional information related to your case, such as paperwork you submitted to USCIS, documents you received from USCIS, or
other information or documentation you feel is important to your case.
no file selected

Attachments

Rename to:

Attach Another

Fax Attachments

Check this if supporting documentation is going to be Faxed.

Mail Attachments

Check this if supporting documentation is going to be Mailed. Do not mail original documents. Only mail copies of documents.
Validate

Verification ( Section 14, 15, 16, and 17 )
14. Consent: If you are the beneficiary of a pending petition, and you are not a lawful permanent resident or a U.S. citizen, the petitioner must sign here to give
consent to the release of his or her information.
Legal Notice - If you are a duly authorized third party representative who is completing this form and signing on behalf of the petitioner, note that by signing this
form you are assuming responsibility under penalty of perjury that you have express permission from the petitioner to sign on the petitioner’s behalf.
15. Verification: This item should be signed and completed by the the person encountering difficulties with USCIS (applicant/beneficiary/petitioner).
16. Declaration: The person encountering difficulties with USCIS (applicant/beneficiary/petitioner) should sign his or her name.
I certify, under penalty of perjury under the laws of the United States of America, that the foregoing is true and correct, and that I am the the person
encountering difficulties with USCIS (applicant/beneficiary/petitioner) and I understand that any falsification of this statement is punishable under the provisions
of 18 U.S.C Section 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years or both, and that requesting or obtaining an
record(s) under false pretenses is punishable under the provisions of 5 U.S.C. Section 522a(i)(3) by a fine of not more than $5,000.
Further: pursuant to 5 U.S.C Section 522a(b), I authorize the Office of the Citizenship and Immigration Services Ombudsman to release any and all
information relating to me to U.S. Citizenship and Immigration Services.
I declare under penalty of perjury that the foregoing is true and correct.
* Signature of the person encountering difficulties with USCIS (applicant/beneficiary/petitioner):
By typing your name here you are legally signing this form.
17. Attorney/Accredited Representative Declaration: If you are an attorney or accredited representative, you should sign your name. Otherwise, the person
encountering difficulties with USCIS (applicant/beneficiary/petitioner) should sign his or her name.
I declare that I have prepared this document at the request of the person named in Number 14/15 and that the responses are based on all information of
which I have knowledge.

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Case Problem Submission Worksheet (CIS Ombudsman DHS Form 7001)

* Signature of Attorney/ Accredited Representative:
By typing your name here you are legally signing this form.
Validate

Submit

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