DHS Form 7001 Citizenship and Immigration Services OMBudsman

DEPARTMENT OF HOMELAND SECURITY
CITIZENSHIP AND IMMIGRATION SERVICES OMBUDSMAN

CASE ASSISTANCE FORM

Ombudsman DHS Form 7001
OMB Control Number: 1601-0004
Expiration Date: 12/31/2017

NOTE: Please read the attached instructions before submitting this form, and provide as much information as possible.
1. Name: Please identify the name of the individual or employer (applicant/beneficiary/petitioner) encountering difficulties
with USCIS. Do not enter the attorney/law firm's name here.
Middle Name:
Last Name:
First Name:
Mr.
Ms.
or
Name of Petitioning Company/Organization:
2. Date of Birth, Country of Birth, Country of Citizenship:
Date of Birth: (mm/dd/yyyy)
Country of Birth:

Country of Citizenship:

3. Alien Registration Number (A-Number): The A-Number appears in the following format: A123-456-789.
NOTE: Not every person is assigned an A-Number by USCIS. If you do not have an A-Number, leave this section blank.
A-Number:
A
4. Contact Information: Please provide the contact information of the individual or employer (applicant/beneficiary/
petitioner) encountering difficulties with USCIS. Please include the primary E-Mail address for the Ombudsman to provide
updates.
Street Address:
Apartment/Suite:
City:
State/Province:

Zip Code:

Phone Number:

Fax Number:

Primary E-Mail Address (to receive Ombudsman updates):
5. Applications/Petitions Filed: List all applications and/or petitions pending with USCIS related to your case inquiry.
USCIS Form Number:

Receipt Number:

USCIS Receipt Date:

USCIS Form Number:

Receipt Number:

USCIS Receipt Date:

Receipt Number:
USCIS Form Number:
USCIS Receipt Date:
6. Type of Immigration Benefit Sought: Please provide the type of immigration benefit sought from USCIS.
a.

Nonimmigrant Status (ex. Student)

b.

Immigrant Status (ex. Permanent Residency)

c.

Citizenship or Naturalization

d.

Asylum or Refugee Status

e.

Interim Benefits (ex. Employment Authorization)

f.

Waiver (ex. Waiver of Grounds of Inadmissibility)

g.

Other (specify):

7. Reason for Inquiry/Case Assistance Request: Check all that apply. Provide a description in section 8 and add
documentation related to your inquiry.
a.
b.

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/delay in processing by USCIS.
I am facing a problem that was not resolved through the normal processes provided by USCIS.

c.

I am experiencing processing delays with a case that is beyond anticipated processing times.

d.

I am incurring or am about to incur significant and unusual costs (including fees for professional representation
that are not normally incurred).
I have received an action or decision that involves clear errors of fact, or gross and obvious misapplication of
the relevant law by USCIS.

e.
f.

Other (specify):

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8. Description of Your Case Problem: Describe the difficulties experienced with USCIS including all responses USCIS
provided. Attach relevant correspondence concerning actions taken to resolve the issue before submitting with the
Ombudsman's Office including: receipt notices; requests for evidence; decisions; notices and any other correspondence
from USCIS about your case. Attach additional pages if needed.

9. Prior Actions Taken to Remedy the Problem: Check all that apply and provide the additional information requested for each
selection in the space provided. Note that if selecting Option a - "Visited myUSCIS Case Status at www.uscis.gov", you must
indicate the additional actions (b through g) taken to remedy the problem before submitting your inquiry to the Ombudsman.
a.
b.

Visited myUSCIS Case Status at www.uscis.gov. and
Contacted the National Customer Service Center (NCSC) for information and/or assistance regarding this case
at their toll-free number 1-800-375-5283.
Provide referral number (also referred to as an SRMT Number):

c.

Attended an InfoPass Appointment with USCIS. Provide InfoPass Confirmation Number:

d.

Sent an E-mail to USCIS. Provide date E-Mail sent:
Provide USCIS E-mail address:

e.

Contacted a U.S. Government Department or Agency for assistance.
Provide name and contact information:

f.

Contacted a U.S. Congressional Representative for assistance.
Provide name and contact information:

g.

Other. Please describe:

10. Person Preparing This Form: Please indicate who is completing this form.
a.
b.
c.
d.

The individual or employer encountering difficulties with USCIS:
A representative of a company/organization:
An attorney/accredited representative:
Other (specify):

11. Attorney or Accredited Representative: Please complete this section if you are an attorney or an accredited
representative preparing this form on behalf of the individual or employer encountering difficulties with USCIS.
Please attach a copy of your Form G-28.
First Name:
Middle Name:
Last Name:
Street Address:
Country:

Suite:
E-Mail Address:

City:

State/Province:
Phone Number:

Zip Code:

Fax Number:

1.

I have submitted a Form G-28 to USCIS as the attorney/accredited representative regarding applications or
petitions related to this inquiry. A copy of my Form G-28 is attached.

2.

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.

3.

I am an attorney and a member in good standing of the bar 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.
Name of Court:
State of Admission:

4.

Other (Explain fully):

Signature of Attorney/Representative:
DHS Form 7001 (6/15)

Date (mm/dd/yyyy):
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12. Consent: Please note that if you are the beneficiary of an immigration petition, consent of the individual or employer
that submitted the petition on your behalf is required. The petitioner must sign.
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 individual or employer encountering difficulties with USCIS 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 any record(s) under false pretenses is
punishable under the provisions of 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000. Further, pursuant to 5 U.
S.C. Section 522a(b), I authorize the Citizenship and Immigration Services Ombudsman to release any and all information
relating to the above mentioned individual or employer to U.S. Citizenship and Immigration Services.
Signature:

Date (mm/dd/yyyy):

Print Name:

DHS Form 7001 - Privacy Act Statement
Authority: 6 U.S.C. Section 272 authorizes the collection of this information.
Purpose: The Ombudsman's Office will use the information provided to assist an individual or employer with his or her Case
Assistance Request.
Routine Use: The information will be used by and disclosed to DHS personnel and contractors or other agents who need
the information to assist in activities related to your Case Assistance Request. DHS may also share the information provided
in accordance with the routine uses listed in DHS/CISOMB-001 Virtual Ombudsman System of Records Notice, 75 FR
18857 (April 13, 2010).
Disclosure: Furnishing this information is voluntary. However, failure to provide the requested information may delay or
prevent the Ombudsman's Office from providing assistance with your case.
Paperwork Reduction Act Notice:
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, 245 Murray Lane SW, Mail Stop 0180, Washington, D.C. 20528-0180], ATTN: PRA OMB 1601-0004.

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INSTRUCTIONS
General Information
Introduction:
The Office of the Citizenship and Immigration Services Ombudsman (Ombudsman's Office) assists individuals and
employers who are unable to resolve problems directly with U.S. Citizenship and Immigration Services (USCIS). To receive
assistance with a problem regarding an application or petition with USCIS, you may submit this form to the Ombudsman's
Office after trying all means to resolve the to resolve the problem with USCIS. Please note the Ombudsman's Office cannot
provide legal advice. It is an independent office within the U.S. Department of Homeland Security (DHS) and is not part of
USCIS. Please note 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.
Before you Submit this Form to the Ombudsman:
Before asking the Ombudsman's Office for help with an application or petition, you first should try to resolve the problem with
USCIS by using all of the following methods:
Obtain information about the case at myUSCIS Case Status at www.uscis.gov.
Contact the National Customer Service Center (NCSC) for assistance at 1-800-375-5283.
Request assistance from USCIS using their e-Request tool to check on appointment accommodations,
typographic errors, delayed delivery of documents, notices or cards by mail or if a pending application is beyond
the normal processing times.
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 www.infopass.uscis.gov.
General Instructions:
The Ombudsman's Office does not accept fees.
If extra space is needed, you may attach additional pages and indicate the section number.
If a particular item does not apply to your case assistance request, please write "N/A."
Please attach copies of any documents you received from or sent to USCIS or any other government entity that
is related to your request for assistance. Additionally, you may submit other information or documentation that will
help the Ombudsman's Office review your request for assistance. Please do not send original documents.
Type or print legibly in black or blue ink.
This form is not required. However, a properly completed form ensures that the Ombudsman's Office receives the
necessary information to assist with your case. If you do not use the form, you may experience a delay in the
processing of your request for assistance.
Submitting the Form
Please submit your completed, signed and dated form, including supporting documentation, to the Ombudsman's Office by
one of the following:
Ombudsman website: (recommended)
Submit an electronic DHS Form 7001 through Ombudsman Case Assistance Online at www.dhs.gov/case-assistance which
provides a direct, paperless submission of requests for assistance to the Ombudsman. The Ombudsman automatically assigns
a case number once submission has been completed with an acknowledgement e-mail sent to the e-mail address filled in on
the form. Using the electronic form will help the Ombudsman to process your case assistance request with minimal delays.
E-Mail:
[email protected]

Fax:
(202) 357-0042

U.S. Mail:
Citizenship and Immigration Services Ombudsman
U.S. Department of Homeland Security
Attention: Case Assistance
245 Murray Lane SW, Mail Stop 0180
Washington, D.C. 20528-0180

Expedited Delivery Services:
Citizenship and Immigration Services Ombudsman
U.S. Department of Homeland Security
Attention: Case Assistance
245 Murray Lane SW, Mail Stop 0180
Washington, D.C. 20528-0180

Due to security measures with the U.S. Government mail system, cases mailed (even those sent by expedited delivery
services) will be delayed.
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Completing the Form
The items below correspond to sections in the form.
1. Name: Please provide the name of the individual or employer encountering difficulties with USCIS (applicant/beneficiary/
petitioner). Please provide a full legal name (first name, middle name, last name). Please also provide any name variations
or additional names used on an additional page. Employers should provide the name of the company or organization
identified in the USCIS petition. Please do not enter the attorney's or law firm's name in this section.
2. Date of Birth: Please provide the month/day/year (for example July 4, 1976 should read 07/04/1976).
Country of Birth and Country of Citizenship: Please provide both a country of birth and a country of citizenship
3. Alien Registration Number (A-Number): Please provide the A-Number, if applicable. You may find the A-Number on
documents received from USCIS, such as Employment Authorization Documents and Notices of Action. Please note that
USCIS does not assign an A-Number to everyone applying for an immigration benefit.
4. Contact Information: Please provide contact information for the individual or employer encountering difficulties with
USCIS. Please include the Primary E-Mail address where you would like to receive updates from the Ombudsman's Office.
5. Applications/Petitions Filed: Please identify each application/petition by form number USCIS receipt date and receipt
number. Form numbers are located on the lower right corner of USCIS forms (for example: Form I-485). The receipt number
and receipt date are located on the top left corner of the Notice of Action (Form I-797) received from USCIS in response to
the application/petition filed.
6. Type of Immigration Benefit Sought: Please provide the type of immigration benefit application/petition submitted to
USCIS.
7. Reason for Inquiry/Case Assistance Request: Check all that apply. Please indicate if any of the option(s) listed apply to
this case. Provide a description in section 8 and add documentation related to your inquiry.
8. Description of Your Case Problem: Please provide a detailed description of the case inquiry. Please attach additional
pages if necessary.
9. Prior Actions Taken to Remedy the Problem: Check all that apply. Please choose the option(s) that indicate the action
(s) taken to resolve the problem relating to applications or petitions with USCIS. Please provide a brief explanation of the
result of your actions such as: if you were contacted by a congressional office/representative, what, if any, action was taken
and what was the type, nature of the contact - phone call; letter; e-mail; etc. Please note: If an inquiry is still pending with a
Congressional representative then that inquiry should come to resolution prior to having our office look into the matter.
10. Person Preparing This Form: Please indicate who is preparing this form. If you are preparing this form for someone
else, please also fill out section 11. Important: If you are the beneficiary of a pending petition, the petitioner must provide
consent to the release of information relating to your case.
11. Attorney or Accredited Representative: Please complete this section if you are an attorney, accredited representative,
representative of an organization or anyone else preparing this form on behalf of the person encountering difficulties with
USCIS. If you filed a Form G-28 with USCIS, please include a copy with this form.
12. Consent: Signing this form gives the Ombudsman's Office permission to share and receive information about
applications/petitions filed with USCIS. It certifies that the information shared with the Ombudsman's Office is true and
correct to the best of your knowledge. Important: If you are the beneficiary of an immigration petition, please have the
petitioner who submitted the petition on your behalf sign section 11 of the form. The beneficiary does not sign this form.
Legal Notices
Penalties for Submitting Incorrect Information:
Whoever willfully and knowingly falsifies a material fact, makes a false statement or makes use of false documents will be
fined up to $10,000, imprisoned for up to five (5) years, or both. 18 U.S.C. Section 1001. Requesting or obtaining any record
(s) under the false pretenses is punishable under the provisions of 5 U.S.C. Section 552a(i)(3) by a fine of not more than
$5,000.
Authority for Collecting Information:
The function of the Citizenship and Immigration Services Ombudsman is:
(1) to assist individuals and employers in resolving problems with the Bureau of Citizenship and Immigration Services;
(2) to identify areas in which individuals and employers have problems in dealing with the Bureau of Citizenship and
Immigration Services; and (3) to the extent possible, to propose changes in the administrative practices of the Bureau of
Citizenship and Immigration Services. Homeland Security Act of 2002 Section 452.
Please visit the Ombudsman's website at www.dhs.gov/topic/cis-ombudsman to see Frequently Asked Questions and more
information about filing a case assistance inquiry.
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