DHS Request For Case Assistance Form 7001-10212022-FINAL
DHS Request For Case Assistance Form 7001-10212022-FINAL
DHS Request For Case Assistance Form 7001-10212022-FINAL
Required Information/Documents
Please have the following information available to complete this form, if applicable:
• A-Number;
• USCIS form and receipt number(s) for each application or petition for which you seek our assistance;
• Correspondence with USCIS (e.g., Form I-797, Notice of Action);
• USCIS response(s) to inquiry; and
• Any other information or documentation that is important to the case.
Form G-28: If you are a legal representative, you must submit the Notice of Entry of Appearance (Form G-28) that you
have already submitted to USCIS for the application/petition for which you seek our assistance.
For expedite requests: If you are requesting expedited assistance, you must submit documentary evidence of the
urgency or hardship (e.g., medical records, financial documents, letter from employer, etc.) that demonstrates how the
individual or employer will be unable to withstand the hardship. Please do not include private or personally identifiable
information that is not relevant to assessing your request.
How to Submit This Form
Please submit your completed, signed, and dated DHS Form 7001, including supporting documentation, by one of the
following methods:
• Online: Submit your request for case assistance online at: www.dhs.gov/topic/cis-ombudsman/forms/7001 . If you are
unable to upload all documents, you may submit documents by email to cisombudsman@hq.dhs.gov. Please include
the CIS Ombudsman request number received via email after submitting DHS Form 7001 online.
• Email: If you are outside the United States and unable to access our online case assistance portal, email DHS Form
7001 and all supporting documents to cisombudsman@hq.dhs.gov.
Only mail or fax documents if you do not have computer access.
• Fax: (202) 357-0042
• U.S. Mail:
Office of the Citizenship and Immigration Services Ombudsman
Department of Homeland Security
Mailstop 0180
Washington, D.C. 20528
1A. Actions Taken with USCIS for Resolution 1. Requested assistance from USCIS using its
e-Request (https://egov.uscis.gov/e-request/Intro.do) or other
Check all that apply and provide the following
online tools, e.g., to request an appointment or interview,
information in the box, where applicable:
correct typographic errors, inquire about delayed delivery of
• The date and email or phone number used to documents, notices or cards by mail, or if a case is beyond
call the USCIS Contact Center; the published processing times (https://egov.uscis.gov/
processing-times)
• The response from USCIS; and
Emailed the lockbox
• The service request or reference/confirmation 2.
number, or the representative's name or 3. Called the USCIS Contact Center at 1-800-375-5283
identification number, as well as the call date
4. For refugee applicants: Emailed USCIS from your registered
and phone number you called from.
email address to seek assistance
Our office will not contact USCIS on your behalf 5. For T visa, U visa, or Violence Against Women Act (VAWA)
unless you have indicated prior actions taken with benefits: Contacted the appropriate USCIS service center
USCIS.
6. Other
See the USCIS Contact Us web page
(https://www.uscis.gov/about-us/contact-us) for Please describe the response(s) USCIS provided and attach all
additional information and addresses. relevant correspondence and/or screenshots:*
2. Reason(s) for Requesting Case Assistance Mailing issues, including non-delivery of correspondence and/or
immigration documents
Check all that apply and provide a clear and
concise explanation of the issue and how you Beneficiary may “age-out” of eligibility for the requested
would like the CIS Ombudsman to assist. immigration benefit. (see Child Status Protection Act web page:
https://www.uscis.gov/green-card/green-card-processes-and-
procedures/child-status-protection-act-cspa)
Certain cases involving U.S. military personnel and their families
Applications or petitions that were improperly rejected by USCIS
due to clear errors of fact or obvious misapplication of the relevant
law by USCIS
3. Applications or Petitions Filed USCIS Form USCIS Receipt Date: USCIS Receipt Number:
Number:*
List all USCIS application/petitions related to your
issue. Check the box next to the USCIS receipt
number for which you seek assistance.
USCIS Form USCIS Receipt Date: USCIS Receipt Number:
If you do not have a receipt number, please
Number:
provide a USCIS form number and receipt date.
4. Type of Benefit Sought Employment (e.g., Forms I-129, I-140, and I-485 based on I-140)
Check the type of immigration benefit that you are Family (e.g., Forms I-130, I-751, and I-485 based on I-130)
seeking from USCIS. Select only one.
Humanitarian (e.g., Forms I-360 (SIJ, SIV, VAWA), I-589, I-730, I-821D,
and I-918)
Citizenship/Naturalization
Student (e.g., Form I-539 and related Form I-765 OPT)
Military (e.g., Form N-400, MAVNI, and PIP)
Other (specify):
Complete Section 11 to provide beneficiary [The employer is the company or organization that submitted the
information. USCIS petition.]
If you have a family member who also needs assistance, please
check this box and have them submit a separate DHS Form 7001.
Send an email with all related request numbers to
cisombudsman@hq.dhs.gov so we may link your cases together.
6. Contact Information Street Address:*
Other:
9. Consent for Applicant/Petitioner I certify, under penalty of perjury under the laws of the United States
The applicant/petitioner must sign this section. If of America, that the foregoing is true and correct, and that I am the
they do not, we will treat your request as individual or employer encountering difficulties with USCIS and I
incomplete. 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 Office of the Citizenship and Immigration
Services Ombudsman to release all information relating to the
individual or employer above mentioned to USCIS.
Email Address:*
Work Number:*
Alternative Number:
10. Consent for Attorney or Accredited I am an accredited representative of a religious, charitable, social
Representative (continued) service or similar organization established in the United States
and recognized by the Department of Justice's Executive Office of
Immigration Review.
I have submitted to USCIS a Form G-28 as the attorney/
accredited representative regarding applications/petitions for
which I seek assistance. A copy of my Form G-28 is attached.
Full Name:*
Country of Birth:*
Country of Citizenship:*
Full Name:*
Country of Birth:*
Country of Citizenship:*
Full Name:*
Country of Birth:*
Country of Citizenship:*
Full Name:*
Country of Birth:*
Country of Citizenship:*
Full Name:*
Country of Birth:*
Country of Citizenship:*
Full Name:*
Country of Birth:*
Country of Citizenship:*
12. How did you learn about the CIS Ombudsman's casework service?
Referred by USCIS DHS Website Search Engine Legal Representative Congressional Staff
Community-Based Organization Social Media Received a Stakeholder Message through GovDelivery
Friend/Other:
Purpose: The CIS Ombudsman will use the information provided to assist an individual or employer with the request for
case assistance.
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 Case Assistance Analytics and Data Integration
System of Records Notice, 86 FR 59408, October 27, 2021.
Disclosure: Providing this information is voluntary. However, failure to provide the requested information may delay or
prevent the CIS Ombudsman from assisting with your case.
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 1601-0004 and expiration date 09/30/2025. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the CIS Ombudsman at the
email or mailing address listed above.