Form DHS-7001 CIS OMBudsman Case Problem Submission Worksheet

Case Problem Submission Worksheet
(CIS Ombudsman Form DHS-7001)

Department of Homeland Security
Citizenship and Immigration Services Ombudsman

Instructions
General Information.
1. Who May Use This Form?
If you are experiencing problems during the adjudication
of an immigration benefit with U.S. Citizenship and
Immigration Services (USCIS), you can submit this
worksheet form. You may also use this form to submit a
case problem on behalf of somebody else who
experiences a case problem with USCIS. If you submit a
case problem on behalf of somebody other than yourself,
you should ensure that the person the case problem is
about (the applicant for a USCIS immigration benefit, or
the petitioner who seeks to obtain an immigration benefit
for a third party) consents to your inquiry (see section
15).

2. Do I Have to Use This Form to Submit a
Case Problem to CIS Ombudsman?
You do not have to use this form to submit your case
problem to CIS Ombudsman. However, by submitting a
properly completed form, the CIS Ombudsman will
receive the necessary information to process your case
problem. If you do not use the form and do not provide
us with the necessary information, you may experience a
delay in the processing of your case problem.

3. When Should I Submit a Case
Problem to CIS Ombudsman?
You should contact the CIS Ombudsman if you have an
ongoing or immediate issue with USCIS, such as:
You are facing, or are 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, or a problem, which could not
be resolved through the normal processes provided for by
USCIS;
Your case experienced processing delays beyond
anticipated processing times;
You will incur, or are about to incur, significant and
unusual costs (including fees for professional
representation that are not normally incurred);
Have not received a response or resolution within the
anticipated time frames as published by USCIS.

4. Do I Have to Do Anything Before I Can
Submit a Case Problem to CIS Ombudsman?
It is best if you contact our office for assistance after
utilizing other resources for case problems with USCIS,
such as:
USCIS Case Status Service Online at http://www.uscis.gov;
Made an InfoPass appointment at the local office;
Contacted the National Customer Service Center (NCSC)
for assistance at (800) 375-5283.
While we do not require that you take these steps before you
contact our office, the above listed resources can resolve
many frequently asked questions such as (1) what forms to
file; (2) where to file a particular form; (3) how to notify
USCIS of a change of address; (4) how to inquire about
processing times at the various service centers or field offices
or (5) how to receive case status updates. Additionally,
certain information can be obtained from USCIS directly,
such as information about individual immigration benefits.
NOTICE: Please be aware that CIS Ombudsman cannot
provide legal advice. Our office does not have the
statutory authority to tell you what type of immigration
benefit you may be eligible for or how to remedy your
particular immigration situation.

5. What Are the General Filing
Instructions for This Form?
Type or print legibly in black ink.
If extra space is needed to complete any item, please attach
a continuation sheet and indicate the item number.
If you feel that a particular item does not apply, please
indicate by writing "N/A."
Please attach copies of any documentation you received
from or sent to USCIS or any other government entity in
relation to your case problem. Any additional
documentation that is helpful to your case should be
submitted. Do not send us original applications or original
documentation.

6. Do I Need to Submit a Fee
Along With This Form?
No fee is required. Please do not send us any fees.
Form DHS-7001 (08/24/06)

7. Where Should I Send the Completed Form?
Please mail your completed, signed and dated form, including
supporting documentation, to the following address:
Via Regular Mail:
Citizenship and Immigration Services Ombudsman
Department of Homeland Security
Attention: Case Problems
Mail Stop 1225
Washington, D.C. 20258-1225
Via Courier Service:
Citizenship and Immigration Services Ombudsman
ATTN: Case Problems
Department of Homeland Security
245 Murray Lane
Mail Stop 1225
Washington, D.C. 20258-1225
Due to security concerns, mail is screened prior to being
forwarded to our office. Please allow up to 14 days from the
mailing date until our office receives your case problem. We
confirm in writing the receipt of each case problem received
within two to four business days in writing.

8. What Assistance Does the Ombudsman
Provide to Resolving Case Problems?
Once we receive your case problem, we will review your case,
determine if we are able to assist you, and if appropriate, forward
your case to USCIS for resolution. If for some reason we are not
able to help you obtain a resolution to your case problem, we will
inform you of the reasons in writing. If another government office
or agency is better able to assist you with your case problem, we
will make every effort to provide you with the contact information
of that office or agency.
If you believe that our office should have accepted your case for
assistance, you may resubmit your case problem with additional
explanations as to why your case problem should have been
accepted.

9. Can the Ombudsman Provide Legal Advice?
CIS Ombudsman cannot:
Adjudicate immigration applications or petitions;
Reverse an adverse decision issued by USCIS;
Serve as a substitute for legal options available to you to
correct a problem; or
Provide legal advice.
NOTE: CIS Ombudsman only has jurisdiction to provide
assistance resolving case problems that arise under the jurisdiction
of USCIS. The Ombudsman is not able to provide assistance with
case problems that arise under the jurisdiction of other agencies
dealing with immigration-related issues, such as:
The Immigration Courts and the Board of Immigration
Appeals (BIA), which are part of the Executive Office
of Immigration Review (EOIR);

The Department of Justice (DOJ);
Customs and Border Protection (CBP);
Immigration and Customs Enforcement (ICE);
Department of State (DOS), including the National Visa
Center (NVC) and U.S. Embassies andConsulates; or
Department of Labor (DOL).

10. Privacy Act Requirements.
When you submit your information and case problem to the
office of CIS Ombudsman, you are consenting to our review
of your information and contacting USCIS on your behalf.
You also consent to the release of your information to
authorities within USCIS or any person acting on behalf of
USCIS.
In addition, it's the CIS Ombudsman's statutory mandate
under the Homeland Security Act, Section 452, to capture and
address systemic problems. As such, individual case problems
serve as one of the basis to establish current systemic trends
and problems individuals and employers experience during
the immigration benefits seeking process. For this purpose,
we will remove your personal information and use the
remaining information collected for statistical purposes.
The scope of your consent to release your information is
limited to the furtherance of resolving the case problem
associated with your case, and the capturing of declassified
data to establish systemic immigration problems occuring at
USCIS.
(For additional information, please see Page 3 on these
instruction, "Legal Notification Requirements: What Is
Our Authority for Collecting This Information?")

Specific Instructions.
The following instructions will assist you in completing
the form correctly. The items numbered below correspond to
the section number of the form requesting the particular
information:
1. Name of subject: The "subject" is the person the case is
about. Please enter the person's full legal name (first,
middle, last name). If the person possesses an alias,
provide your alias by indicating "aka" and then listing the
alias and all other legal names.
2. Contact information: Please provide the contact
information of the person the case is about. If you are
submitting the case problem on behalf of somebody else,
please also complete Section 14.
3. Subject's date of birth: Self-explanatory.
4. Subject's country of birth and citizenship:
Self-explanatory.
5. Alien ("A") Number: Provide your alien ("A") number, if
applicable. Note that not every person has an alien number
assigned by USCIS. For example, if you are seeking nonimmigrant status in the United States, you may or may
not have an "A" number. The "A" number can be found
on many frequently issued USCIS documents, such as
work permits or Notices of Actions.
Form DHS-7001(08/24/06) Page 2

6. Type of case problem: Indicate whether the case problem
concerns an individual or an employer.
7. Person preparing this form: Indicate whether the preparer
of this form is the person the case problem is about ("the
subject"), an organization, attorney/representative or
whether you are completing this form in any other capacity
(such as a friend of the family, friend, uncle, etc.).
Important: If you are the beneficiary of an immigration
application and the one submitting the case problem,
you will need the consent of the individual who submitted
the petition on your behalf ("the Petitioner"). In this case,
you are (although the beneficiary) simply a representative
of the Petitioner, and will need the consent of the Petitioner
to submit this case problem (please see also Section 15).
8. Applications and petitions filed: List all applications/
petitions that are currently pending with USCIS and that
pertain to the case problem you are experiencing. List the
applications/petitions by identifying the date when the
application/petition was received by USCIS (Receive date);
the form number of the application/petition, which may be
located on the lower right corner of USCIS form (e.g. ,
Form I-485); and the name of USCIS form (e.g.
Application to Register Permanent Residence or to Adjust
Status).

14. Designated Attorney/Representative: Please complete this
section if you are an attorney, organization or designated
representative who is submitting this case problem. You
are also a representative if you are, for example, a friend
of the person the case problem is about, and if you would
like to assist the individual in resolving the case problem.
15. Consent: For privacy reasons, if you wish USCIS to disclose
all the information in the file, we require the consent of the
petitioner (the person who filed the petition with USCIS). As
a general rule, the person who filed the application/petition
with USCIS has to consent to the submission of a case
problem to our office. This general rule, however, does not
apply if the beneficiary is a lawful permanent resident of
U. S. citizen.
16. Verification: If the person who submitted the inquiry is also
the subject of the inquiry, this section should be signed and
dated by the subject of the inquiry. If a person is the
representative and acts on behalf of the subject the case
problem is about, the representative should sign and date the
verification statement.
17. Declaration: If you are an attorney or representative submitting the case problem you should sign and date the
statement. If you are submitting the case problem for
yourself, and you are the subject of the case problem, you
should sign this statement.

9. Receipt number: Provide the receipt number(s) for the
application(s)/petition(s) currently pending with USCIS.
The receipt number is located on the top left hand corner
of your Notice of Action (Form I-797) you received from
USCIS in response to the application/petition you filed.
Please provide each receipt number associated with
this case.

18. Submission of the worksheet form: Self-explanatory.

10. Immigration status or interim benefit Applied or
Petitioned for: Provide information about the
immigration status or the immigration benefit the person
of the case problem is seeking (non-immigrant, immigrant,
citizenship, naturalization, refugee or asylum status, work
authorization, travel document, etc.)

Section 1001 of Title 18, United States Code states that 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.

Provide also the legal category of the immigration status
you are seeking. If you are unsure about the category,
submit as much information as you can in Number 12
of the form, Description of case problem. If possible,
provide us with a copy of the application you filed with
USCIS so that we will be able to determine what
immigration category you are seeking.
11. Source of case problem: Please choose the options
provided that best describe the source of the case problem.
12. Description of your case problem: Please provide a
detailed description of your case problem. If additional pages
are needed, please attach them on separate sheets of paper.
13. Prior actions taken to remedy the problem: Check all
the boxes that apply to the subject's or the representative's
action(s) already taken to remedy the problem.

Legal Notification Requirements.
1. What Are the Penalties for
Submitting Incorrect Information?

2. What Is Our Authority for
Collecting This Information?
We request the information on this form to carry out our mandate
as provided by Section 452 of the Homeland Security Act of
2002. We need the information to assist individuals and
employers in resolving problems with USCIS; to identify areas in
which individuals and employers have problems in dealing with
USCIS; and to the extent possible, to propose changes in the
administrative practices of USCIS to mitigate problems identified.
When you submit your information and case problem to this
office, you are consenting to our review of your information to our
office and contacting USCIS on your behalf. With the submission
of your case problem, you also consent to the release of your
information to authorities within USCIS or any person acting on
behalf of USCIS. In addition, it's CIS Ombudsman's statutory
mandate under the Homeland Security Act, Section 452, to
capture and address systemic problems. As such, individual case
problems serve as one of the bases to establish current systemic
trends and problems. For this purpose, we will remove your
personal information and use only the remaining information for
statistical purposes.
Form DHS-7001 (08/24/06) Page 3

The scope of your consent to release your information is limited
to the furtherance of resolving the case problem associated with
your case and capturing statistical data to identify systemic
immigration problems.
You do not have to provide us with the particular information
requested. However, if you omit certain information, our office
may not be able to assist you, or the resolution of your case
problem may be delayed.

3. Paperwork Reduction Act Notice.
A person is not required to respond to a collection of information
unless it displays a current valid OMB control number.
The public reporting burden for this collection of information is
estimated to average 60 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaing the data needed and completing and
reviewing the collection of information.
Send comments regarding this burden estimate or any other
aspects of this collection of information, including suggestions
for reducing this burden to cisombudsman@dhs.gov Do not mail
your case problem to this email address.

Form DHS-7001 (08/24/06) Page 4

Case Problem Submission Worksheet
(CIS Ombudsman Form DHS-7001)

Department of Homeland Security
Citizenship and Immigration Services Ombudsman

NOTE: Please read the attached instructions before submitting this worksheet. In completing this worksheet, the "subject" refers to
the person whom the inquiry is about. In submitting your inquiry, please provide as much information as possible. Places requiring your
signature are indicated with the symbol.

1. Name of subject.

First Name:

Middle Name:

Last Name:

The person this case problem is
about who is seeking the
immigration benefit.

2. Contact information.

Street Address:

Apartment/Suite: City:

The contact information of the
person the case problem is about. County:
If you are submitting this form for
someone else, complete number 14.

3. Subject's date of birth.

Zip Code:

E-Mail Address:

State/Province:
Phone Number:

Fax Number:

(with Area Code)

(with Area Code)

Date of Birth: (mm/dd/yyyy)

Please indicate in the following
format: (mm/dd/yyyy).

4. Subject's country of
birth and citizenship.

Country of Birth:

5. Alien or "A" number.

A Number:

Country of Citizenship:

The "A" number appears in the
following format: A123-456-789.

A
NOTE: Not every person is
assigned an "A" number by USCIS. Tip: Your "A" number can be found on many USCIS documents including your
If you do not have an "A" number, work permit.
leave this section blank.
6. Type of case problem.

I am an:

Check all that apply.

7. Person preparing
this form:
Please indicate who is filing this
case problem.

a.

Individual;

b.

Employer;

a.

The person this case problem is about who is seeking the immigration benefit;

b.

An organization on behalf of an individual;

c.

An attorney/representative;

d.

Other (Explain fully);

I am:

8. Applications/Petitions
filed:

Date Application/Petition was
received by USCIS:

USCIS Form Number: USCIS Name of Form:

List all applications or petitions
pending with USCIS that pertain
to your case problem.

Date Application/Petition was
received by USCIS:

USCIS Form Number: USCIS Name of Form:

Date Application/Petition was
received by USCIS:

USCIS Form Number: USCIS Name of Form:

Tip: List all forms that are the subject of this case problem. E.g.: If you are filing for a Green Card
and are experiencing a problem with your work permit application that was submitted with your
Green Card application, list both Forms I-485 (Application Adjustment of Status) and I-765
(Application for Employment Authorization Document) above.

9. Receipt Number.

Receipt Number:

Please do not include dashes
between the characters.
Tip: Your receipt number is located in the top left hand corner of your Notice of Action (USCIS
Form I-797).

Form DHS-7001 (08/24/06)

10. Immigration status or a.
interim benefit applied
or petitioned for:
The subject of the case problem is
applying for immigration status:

b.

As a Nonimmigrant (e.g. extension of a stay
for a visitor for pleasure-business, change of
status to student, fiance/e, temporary worker,
Temporary Protected Status (TPS) etc.)
As an Immigrant (often called
"Green Card" application)
based on:

i.

A marital relationship of less than two years;

ii.

A marital relationship of more than two years;

iii.

A family relationship and is the parent, child,
brother/sister, etc. of the sponsor;

iv.

An employment relationship and is the (future)
employee or the spouse of child of the principle
(future) employee;

v.

Refugee/Asylum;

c.

vi.
For Citizenship or Naturalization;

d.

For Refugee/Asylum;

e.

For Interim Benefits
(Work Permit/Travel
Document, etc.)

Type: i.

ii.
f.

Other (Application for
Waiver, Replacement
Document, etc.)

Type:

Category:
(e.g.: H-1B1, J2,
F1, L1A)

Other;

Employment
Authorization
Document (e.g.:
Work Permit)

Work Permit Category:

Advance Parole Document (Travel Document);
Waiver (I-601/I-212):
Replacement of a Document
Citizenship Certificate
Naturalization Certificate
Permanent Resident Card
Other:
Other:

11. Source of case
problem:

a.

Check all that apply. Provide a
description in Number 12 below,
Description of Your case problem. b.
c.
d.
e.

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, or 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 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 brought this case problem to the attention of USCIS and have not received a
response or resolution within the anticipated time frames;
Other (specify):

12. Description of your
case problem:
Describe the case problem you are
experiencing with USCIS. Attach
additional pages if needed.

Form DHS-7001 (08/24/06) Page 2

13. Prior actions taken to
remedy the problem:

a.

Contacted my attorney/representative who is representing me regarding this issue for
assistance (if represented);

Check all that apply:

b.
c.

Visited USCIS Case Status Service Online at http://www.uscis.gov.
Contacted the National Customer Service Center (NCSC) for information and/or
assistance regarding this case at their toll-free telephone number 1-800-375-5283.

d.

Contacted the following government department/agency for assistance:

e.
Contacted the following congressional representative for assistance:

14. Designated Attorney/
Representative:

First Name:

Please complete this section if you Street Address:
are an attorney, organization or
designated representative who is
submitting this case problem.
County:
If you are the beneficiary of a
pending petition and have
obtained consent from the
1.
petitioner (see Number 15), check
box 3, sign and date.

Middle Name:

Last Name:

Apartment/Suite: City:
Zip Code:

E-Mail Address:

State/Province:
Phone Number:

Fax Number:

(with Area Code)

(with Area Code)

I am an attorney and a member in good standing of the bar of the Supreme Court of the
United States 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.

State of Admission:

Name of Court:

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 the beneficiary of a pending petition and the petitioner is consenting to the release of
information about a pending case to me.

4.

Other (Explain fully):

I have submitted a USCIS Form G-28 as the attorney/representative for the application/
petition for which case problem is being submitted.
Signature of Attorney/Representative:
Date (mm/dd/yyyy):
5.

15. Consent:
If you are the beneficiary of a
pending petition, and you are not a
lawful permanent resident or U.S.
citizen, the petitioner must sign
here to give consent to the release
of his or her information.

16. Verification:
This item should be signed and
completed by the subject of the
inquiry.

Pursuant to 5 U.S.C. Section 552a(b), I authorize U.S. Citizenship and Immigration Services and
CIS Ombudsman to release any and all information relating to me to: [Print or Type Name]. I
declare under the penalty of perjury that the foregoing is true and correct.
Signature of Subject:
Print Subject's Name:

Date (mm/dd/yyyy):

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 subject of the inquiry 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 the
false pretenses is punishable under the provisions of 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.
Further, pursuant to 5 U.S.C. Section 522a(b), I authorize U.S. Citizenship and Immigration Services and
CIS Ombudsman to release any and all information relating to me to : [Print or Type Name].

Signature of Subject:
Print Subject's Name:

Date (mm/dd/yyyy):

Form DHS-7001 (08/24/06) Page 3

17. Declaration:

I delcare that I have prepared this document at the request of the person named in Number 14 and
that the responses are based on all information of which I have knowledge.
If you are an attorney or
representative, you should sign
Print Subject's or Attorney/Representative's Name:
your name. Otherwise, the subject Signature of Representative:
should sign his or her name.
Title (if applicable):

18. Submission:
Case problems may be sent via
regular mail or courier service to
the following addresses:

Date (mm/dd/yyyy):

Send your completed information to:
Via Regular Mail:
Citizenship and Immigration Services Ombudsman
Department of Homeland Security
Mail Stop 1225
Washington, D.C. 20528-1225
Via Courier Mail:
U.S. Citizenship and Immigration Services Ombudsman
Department of Homeland Security
245 Murray Lane
Washington, D.C. 20528-1225

Form DHS-7001 (08/24/06) Page 4