Department of Homeland Security Citizenship and Immigration Services Ombudsman Case Assistance Form (Ombudsman Form DHS-7001) First Name: Middle Name: or Last Name: OMB No. 1601-0004; Exp. 7/31/2018 NOTE: Please read the attached instructions before submitting this form, and provide as much information as possible. 1. Name: Please identify the individual or employer encountering difficulties with USCIS (applicant/beneficiary/ petitioner). Mr. Ms. Petitioner/Company/Organization Name: Street Address: Zip Code: Apartment/Suite: City: E-Mail Address: Phone Number: State/Province: Fax Number: 2. Contact Information: Please provide information on the individual or employer encountering Country: difficulties with USCIS (applicant/ beneficiary/petitioner). 3. Date of Birth: 4. Country of Birth and Citizenship: 5. Alien Registration Number (A-Number): The A-number appears in the following format: A123-456-789. Date of Birth: (mm/dd/yyyy) Country of Birth: A-Number: Country of Citizenship: A The individual or employer encountering difficulties with USCIS. A representative of a company/organization: An attorney/accredited representative. Other (specify): USCIS Form Number: Receipt Number: NOTE: Not every person is assigned an A-number by USCIS. If you do not have an A-number, leave this section blank. a. b. c. d. 6. Person Preparing This Form: Please indicate who is completing this form. 7. Applications/Petitions Filed: USCIS Form Name: List all applications and/or petitions pending with USCIS related to your case inquiry. USCIS Form Name: USCIS Form Number: Receipt Number: USCIS Form Name: USCIS Form Number: Receipt Number: 8. Type of Immigration Benefit: Please provide the type of immigration benefit sought from USCIS. a. b. c. d. e. f. g. Nonimmigrant Status (ex. Student) Immigrant Status (ex. Permanent Residency) Citizenship or Naturalization Asylum or Refugee Status Interim Benefits (ex. Employment Authorization) Waiver (ex. Waiver of Grounds of Inadmissibility) Other (specify): American LegalNet, Inc. www.FormsWorkFlow.com Form DHS-7001 (7/22/2015) 9. Reason for Inquiry: a. Please indicate if any of the options apply. Provide a description in section 10. 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): 10. Description: Describe the difficulties experienced with USCIS. Attach additional pages if needed. 11. Prior Actions Taken: Check all that apply: Please describe the response USCIS provided and attach any relevant correspondence. a. b. c. d. e. Contacted an attorney/accredited representative for assistance. Visited My Case Status at www.uscis.gov. Contacted the National Customer Service Center (NCSC) for information and/or assistance regarding this case at their toll-free number 1-800-375-5283. Attended an InfoPass Appointment with USCIS. Contacted a U.S. Government Agency or Congressional Representative. Please describe: 12. Consent: If you are the beneficiary of an immigration petition, consent of the individual who 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 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. 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 individual or employer above mentioned to U.S. Citizenship and Immigration Services. Signature: Print Name: Date (mm/dd/yyyy): Form DHS-7001 (7/22/2015) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 13. Attorney or Accredited Representative: First Name: Street Address: Country: 1. Middle Name: Suite: E-Mail Address: City: Last Name: State/Province: Phone Number: Zip Code: Please complete this section if you are an attorney, a representative of an organization, an accredited representative, or anyone else preparing this form on behalf of the individual or employer encountering difficulties with USCIS. Fax Number: 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. State of Admission: Name of Court: 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 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. Other (Explain fully): Date (mm/dd/yyyy): 2. 3. 4. Signature of Attorney/Representative: American LegalNet, Inc. www.FormsWorkFlow.com Form DHS-7001 (7/22/2015) Page 3