Better Safeguards Are 

Needed in USCIS Green 

Card Issuance 

November 16, 2016 

OIG-17-11 
 

 

 

DHS OIG HIGHLIGHTS 

Better Safeguards Are Needed in USCIS 

Green Card Issuance 

November 16, 2016 

Why We Did 

This Audit 

In March 2016, we reported 

challenges in U.S. 

Citizenship and Immigration 

Services’ (USCIS) automation 

of benefits processing. We 

conducted this follow-up 

audit to assess the extent to 

which USCIS has 

inappropriately issued Green 

Cards, evaluate its actions to 

recover the cards, and 

assess its actions and plans 

to prevent similar incidents 

in the future. 

What We 

Recommend 

We recommend USCIS 

improve Electronic 

Immigration System (ELIS) 

functionality and develop 

internal controls to avoid 

inappropriate Green Card 

issuance, standardize card 

recovery and tracking efforts, 

prevent unrecoverable card 

use, and enable remote 

identity verification and 

more secure card delivery 

methods. 

For Further Information: 

Contact our Office of Public Affairs at (202) 

254-4100, or email us at 

DHS-OIG.OfficePublicAffairs@oig.dhs.gov 

What We Found 

As we previously reported, USCIS continues to 

struggle to ensure proper Green Card issuance. 

We found that over the past 3 years, USCIS 

produced at least 19,000 cards that included 

incorrect information or were issued in duplicate. 

Most card issuance errors were due to design and 

functionality problems in ELIS, which is being 

implemented to automate benefits processing. 

USCIS’ efforts to address the errors have been 

inadequate. Although USCIS conducted a number 

of efforts to recover the inappropriately issued 

cards, these efforts also were not fully successful 

and lacked consistency and a sense of urgency. 

Over the last 3 years, USCIS received over 

200,000 reports from approved applicants about 

missing cards. The number of cards sent to wrong 

addresses has incrementally increased since 2013 

due in part to complex processes for updating 

addresses, ELIS limitations, and factors beyond 

the agency’s control. 

Improperly issued Green Cards pose significant 

risks and burdens for the agency. Errors can 

result in approved applicants being unable to 

obtain benefits, maintain employment, or prove 

lawful immigration status. In the wrong hands, 

Green Cards may enable terrorists, criminals, and 

illegal aliens to remain in the United States and 

access immigrant benefits. Responding to card 

issuance errors has also resulted in additional 

workload and corresponding costs, as USCIS 

spent just under $1.5 million to address cardrelated customer inquiries in fiscal year 2015 

alone. 

USCIS Response

The USCIS Director concurred with our 

recommendations. 
OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Washington, DC 20528 / www.oig.dhs.gov 

November 16, 2016 

MEMORANDUM FOR: The Honorable Leon Rodriguez 

Director 

United States Citizenship and Immigration Services 

FROM: John Roth ~k"\(.oh_ 

Inspector General 

SUBJECT: Better Safeguards Are Needed in USCIS 

Green Card Issuance 

Attached for your information is our final report, Better Safeguards Are Needed 

in USCIS Green Card Issuance. We incorporated the formal comments from the 

Director of United States Citizenship and Immigration Services in the final 

report. 

The report contains seven recommendations aimed to improve Electronic 

Immigration System functionality, avoid inappropriate Green Card issuance, 

and improve card recovery and delivery efforts. 

Based on information provided in your response to the draft report, we 

consider recommendations 1 through 7 open and resolved. Once your office 

has fully implemented the recommendations, please submit a formal closeout 

letter to us within 30 days so that we may close the recommendations. The 

memorandum should be accompanied by evidence of completion of agreedupon corrective actions and of the disposition of any monetary amounts. 

Please send your response or closure request to 

OIGITAuditsFollowup@oig.dhs.gov. 

Consistent with our responsibility under the Inspector General Act, we will 

provide copies of our report to congressional committees with oversight and 

appropriation responsibility over the Department of Homeland Security. We will 

post the report on our website for public dissemination. 

Please call me with any questions, or your staff may contact Sondra McCauley, 

Assistant Inspector General, Information Technology Audits, at (202) 254-4041 . 

Attachment 
 

 

 

 

 

 

 

 

 

DHS OIG HIGHLIGHTS 

Better Safeguards Are Needed in USCIS 

Green Card Issuance 

Table of Contents 

Background .................................................................................................... 1 

Results of Audit .............................................................................................. 5 

Green Card Issuance Errors Primarily Due to ELIS Problems ................. 5 

Recommendations............................................................................... 12 

Card Recall Efforts Unsuccessful Due to Lack of Consistency and 

Urgency............................................................................................... 12 

Recommendations............................................................................... 14 

Missing Cards Attributable to Multiple Factors .................................... 15 

Recommendations............................................................................... 19 

Improperly Issued Green Cards Increase Risks, Workload, and Costs... 19 

Appendixes 

Appendix A: Objective, Scope, and Methodology ................................. 30 

Appendix B: USCIS Comments to the Draft Report .............................. 32 

Appendix C: Office of IT Audits Major Contributors to This Report ....... 37 

Appendix D: Report Distribution .......................................................... 38 

Abbreviations 

CBP U.S. Customs and Border Protection 

CLAIMS Computer Linked Application Information Management System 

CPMS Customer Profile Management System 

CSPED Customer Service and Public Engagement Directorate 

ELIS Electronic Immigration System 

EPMS Enterprise Print Management System 

FOD Field Operations Directorate 

ICE U.S. Immigration and Customs Enforcement 

OIG Office of Inspector General 

OTC Office of Transformation Coordination 

SCOPS Service Center Operations 

SMI Secure Mail Initiative 

TSC Texas Service Center 

USCIS United States Citizenship and Immigration Services 

USPS United States Postal Service 
 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Background 

Within the Department of Homeland Security, United States Citizenship and 

Immigration Services (USCIS) is responsible for providing accurate and useful 

information to its customers, granting immigration benefits and U.S. 

citizenship, and ensuring the integrity of the immigration system. To carry out 

its mission, USCIS has 19,000 government employees and contractors at 223 

offices worldwide. USCIS provides services through its headquarters office in 

Washington, DC; 5 service centers; 29 district offices; 136 application support 

centers; and 4 regional offices. USCIS asylum offices, the Customer Contact 

Center, the National Records Center, and the National Benefits Center also 

provide services to customers. 

USCIS provides approximately 90 different types of immigration benefits and 

services, including lawful permanent residence. Permanent residence status is 

granted to foreign nationals who have been approved to reside in the United 

States. The Permanent Resident Card (also known as the Green Card) serves as 

evidence its holder has been officially granted immigration benefits, including 

permission to reside and seek employment in the United States. In fiscal year 

2015, USCIS issued nearly 2.1 million Green Cards. Multiple USCIS program 

offices and directorates participate in Green Card processing and mailing, as 

highlighted in figure 1. 

Figure 1: USCIS Organization as of April 2016 

Source: DHS Office of Inspector General (OIG)-generated from USCIS’ website 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

	 The Service Center Operations Directorate (SCOPS) oversees the Service 

Centers responsible for processing and adjudicating most applications 

and petitions that do not require interviews. 

	 The Field Operations Directorate (FOD) oversees field offices that process 

and adjudicate applications requiring interviews and background checks. 

	 The Fraud Detection and National Security Directorate determines 

whether applicants filing for immigration benefits pose a threat to 

national security or safety. 

 The Office of Transformation Coordination (OTC) manages and oversees 

USCIS development of the Electronic Immigration System (ELIS). 

 The Customer Service and Public Engagement Directorate (CSPED) 

manages customer inquiries. 

 The Office of Intake and Document Production, located in the 

Management Directorate, is responsible for card production. 

To receive a Green Card, individuals must be eligible for an immigrant category 

established by the Immigration and Nationality Act.1 The categories include 

seeking employment, refugee or asylum status, permanent residence as the 

family member of a U.S. citizen or permanent resident, and a number of other 

special immigrant programs.2 In most cases, the process to obtain a Green 

Card begins when an individual, an employer, or a family member files a 

petition with USCIS on behalf of the immigrant.3 Once approved, the petition is 

sent to the U.S. Department of State's National Visa Center for assignment of a 

visa number. At this point, eligible individuals may apply for permanent 

residence either outside the United States through consular processing or 

inside the United States through adjustment of status, as depicted in figure 2. 

1

The Immigration and Nationality Act, enacted in 1952, provides basic immigration and naturalization laws 

(Public Law 82–414, 66 Stat. 163).

2 Special programs exist for the widow of a U.S. citizen, battered spouse or child, armed forces member, 

religious worker, and others.

3 Individuals can also petition on their own for visas in certain immigrant categories. However, not all 

immigrant categories require visa petitions. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Figure 2: Green Card Processing 

Source: OIG analysis of USCIS’ current process 

Since May 2013, USCIS processing of new and replacement Green Cards is 

accomplished using ELIS. The OTC implemented this online capability to 

accept the applicant’s USCIS Immigrant Fee and process the Green Card. In 

March 2015, USCIS transitioned the Application to Replace a Permanent 

Resident Card (Form I-90) to ELIS. Both the USCIS Immigrant Fee and the 

Form I-90 were previously processed in USCIS’ Computer Linked Application 

Information Management System (CLAIMS 3). 

The initial processing for the USCIS Immigrant Fee is done in ELIS. First, a 

USCIS data entry clerk or lockbox contractor enters case data for each 

applicant once a Visa Packet or application is received.4 Next, the data is 

forwarded from ELIS to the Electronic Print Management System (EPMS) at one 

of two USCIS card production facilities. Once the card is produced, it is printed 

and placed in a U.S. Postal Service (USPS) priority mail envelope. USCIS uses a 

database, known as Secure Mail Initiative (SMI), to capture and store delivery 

tracking information once the card has been mailed. USCIS works with other 

DHS components, such as U.S. Customs and Border Protection (CBP), U.S. 

Immigration and Customs Enforcement (ICE), and other law enforcement 

agencies to prevent card misuse after issuance. 

The Green Card displays personally identifiable information, including the 

permanent resident’s full legal name, photo, Alien-number, fingerprint, date of 

birth, and country of birth, as well as a number and expiration date, as 

4

Three lockbox facilities, operated by a Financial Agent of the U.S. Department of Treasury, provide intake 

services for data and fee payments for many USCIS form types. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

depicted in figure 3.5 The cards also contain numerous built-in security 

features designed to prevent fraud. The card remains valid for either 2 or 10 

years, depending on whether the individual is granted conditional or 

permanent residence.6 

Figure 3: Example of a Green Card 

Source: USCIS website 

USCIS is responsible for secure and accurate issuance of immigration benefits. 

However, our March 2016 report identified weaknesses in USCIS’ ability to 

effectively carry out its national security and system integrity goals.7 

Specifically, we disclosed that USCIS had sent potentially hundreds of Green 

Cards to the wrong addresses due to an ELIS limitation that prevented USCIS 

personnel from updating customer addresses. We also reported USCIS was 

unable to identify the exact number of cards sent to the incorrect addresses. 

New information regarding the scope and volume of improperly issued Green 

Cards received after publication of our previous report prompted initiation of 

this current audit. 

5 DHS is responsible for assigning Alien-numbers (“A”-numbers) to foreign nationals. 

6 Permanent residents receive 10-year cards that must be renewed upon expiration. Conditional 

permanent residents receive 2-year cards and must apply to remove their conditional status. 

7 USCIS Automation of Immigration Benefits Processing Remains Ineffective, OIG-16-48, March 2016.
 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Results of Audit 

As we previously reported, USCIS continues to struggle to ensure proper Green 

Card issuance. We found that over the past 3 years, USCIS produced at least 

19,000 cards that included incorrect information or were issued in duplicate. 

Most card issuance errors were due to design and functionality problems in 

ELIS, which is being implemented to automate benefits processing. USCIS’ 

efforts to address the errors have been inadequate. Although USCIS conducted 

a number of efforts to recover the inappropriately issued cards, these efforts 

also were not fully successful and lacked consistency and a sense of urgency. 

Over the last 3 years, USCIS received over 200,000 reports from approved 

applicants about missing cards. The number of cards sent to wrong addresses 

has incrementally increased since 2013 due in part to complex processes for 

updating addresses, ELIS limitations, and factors beyond the agency’s control. 

Improperly issued Green Cards pose significant risks and burdens for the 

agency. Errors can result in approved applicants being unable to obtain 

benefits, maintain employment, or prove lawful immigration status. In the 

wrong hands, Green Cards may enable terrorists, criminals, and illegal aliens 

to remain in the United States and access immigrant benefits. Responding to 

card issuance errors has also resulted in additional workload and 

corresponding costs, as USCIS spent just under $1.5 million to address cardrelated customer inquiries in fiscal year 2015 alone. 

Green Card Issuance Errors Primarily Due to ELIS Problems 

USCIS personnel rely on a number of systems, including ELIS, to conduct 

electronic processing of Green Cards. However, continual system errors have 

caused at least 19,000 cards to be issued with incorrect information or in 

duplicate over the last 3 years. Since ELIS implementation in 2013, the 

percentage of Green Cards issued in error has steadily increased each year. 

USCIS efforts to address the errors have been inadequate. 

Estimated Number of Incorrect Green Cards Issued 

USCIS provided information on at least 12 episodes in which USCIS issued 

incorrect Green Cards between July 2013 and May 2016. Each episode 

resulted in between 19 and 5,434 incorrect Green Cards being issued. USCIS 

personnel we interviewed did not have complete or accurate information readily 

available to account for all improperly issued cards. However, multiple offices 

provided records of each episode they were aware of over roughly the past 3 

years.8 

8 We gathered information from the OTC, FOD, and SCOPS to quantify the extent of card errors. 

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Episode* Date Reported Number

of Cards Affected

Cause

1. Incorrect expiration dates July 2013 2,466 ELIS

2. Incorrect names or date of birth May 2014 5,282 ELIS

3. Incorrect “residence since” date Winter 2014 3,663 OTHER

4. Duplicate cards issued June 2015 5,438 OTHER

5. Duplicate cards issued June 2015 36 CLAIMS

6. Incorrect expiration dates June 2015 772 CLAIMS

7. Incorrect birth and “residence since” date September 2015 219 ELIS

8. Incorrect photos November 2015 369 ELIS

9. Duplicate cards issued March 2016 174 ELIS

10. Duplicate cards issued April 2016 19 ELIS

11. Duplicate cards issued April 2016 242 ELIS

12. Duplicate cards issued May 2016 321 ELIS

Total Cards Issued with Incorrect Data 12,771

Total Duplicate Cards 6,230

Total Card Errors 19,001

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Based on our analysis of the data provided, we determined approximately 

13,000 cards were printed and issued with incorrect personal information, 

such as the wrong name or date of birth. Additionally, over 6,200 duplicate 

cards were sent out to individuals who should have each received only one 

card. The results of our analysis are listed in table 1 below. 

Table 1: Episodes of Green Card Errors and Duplicates from 2013–2016 

* Card errors are denoted in blue, duplicate cards in grey 

Source: OIG analysis of USCIS data 

Green Cards Issued with Incorrect Data 

As shown in table 1, USCIS mistakenly issued nearly 13,000 Green Cards with 

incorrect personal information to applicants between July 2013 and November 

2015. All but two episodes occurred as a result of ELIS design errors or other 

problems that disrupted the automated process. Also, ongoing efforts to 

migrate cases from a previous version of ELIS, called ELIS 1, to the new version 

of ELIS have caused multiple errors.9 Collectively, these problems caused cards 

to be generated and issued with a combination of errors regarding name, date 

of birth, gender, expiration date, and incorrect photos. 

For example: 

	 In July 2013, over 2,400 immigrants approved for 2-year conditional 

residence status were inadvertently issued cards with 10-year expiration 

                                                      

9 ELIS 1 refers to the legacy version of ELIS, which was updated in August 2015. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

dates. In other words, an applicant who should have received a card with a 

2-year expiration date had a card that was valid for 10 years. The OTC 

traced the cause of this error to a source database containing incorrect data 

that was populating the expiration date field. 

	 In May 2014, approximately 5,280 cards were generated in ELIS and issued 

with the incorrect name and/or dates of birth. For example, applicants’ 

cards were printed with “No Given Name” as their first name and with their 

first and last names combined as the last name. In addition, some 

immigrants received cards with mismatched photos and fingerprints. The 

OTC identified multiple root causes for these errors. For one, a system 

release for new functionality inadvertently introduced an error to the 

dataflow. Also, a technical error allowed ELIS to include the immigrant’s 

information on another family member’s card. 

	 In September 2015, ELIS generated roughly 170 cards with the incorrect 

date of birth; all of the cards were generated with January birth dates. This 

issue stemmed from a legacy ELIS data migration effort that incorporated a 

faulty date pattern that set all applicants’ birth dates to January. 

	 In November 2015, nearly 370 cards were mistakenly issued with incorrect 

photos that were mismatched across family members. For example, a child’s 

card had a parent’s photo. The OTC stated that this error also occurred 

during data migration efforts. In this case, a technical glitch enabled 

random association of photos across multiple family members. 

Unrelated to ELIS, USCIS also issued Green Cards with the wrong date 

information on two separate occasions in 2014 and 2015. These episodes 

occurred during the processing of I-90 applications to replace Green Cards. 

One episode resulted from a data entry mistake. Specifically, in the winter of 

2014, USCIS Adjudication Officers incorrectly entered the application approval 

date in the wrong field, causing more than 3,700 cards to be issued with the 

wrong “residence since” date. The other episode, in June 2015, was caused by 

incorrect data in a system field in CLAIMS 3. In this instance, a card 

production software update in CLAIMS 3 caused a miscalculation in the way a 

card expiration date would be system generated. This coding error resulted in 

nearly 800 cards issued with the 2-year expiration date incorrectly calculated 

from the time the application was approved, rather than from the adjustment 

of status date.10 

It should be noted that although the number of errors remains a concern, it 

represents a small percentage of the total number of Green Cards issued by the 

agency each year. For example, in FY 2015, card errors accounted for .48 

percent of roughly 2 million cards that were produced and mailed. Also, the 

10 Per the U.S. Department of State, the expiration date is 2 years from the date the alien obtains lawful 

permanent resident status. 

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0.10%

0.20%

0.30%

0.40%

0.50%

FY13 FY14 FY15

Percentage of Errors Per Cards

Produced

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

individuals who received incorrect cards in these instances had followed the 

proper procedures and security checks and thus were legitimately approved to 

become permanent residents. However, the number of errors has increased 

steadily over the past 3 years. Figure 4 shows the steady increase in Green 

Card errors each year, from fiscal years 2013 to 2015. 

Figure 4: Percentage of Errors per Cards Issued Over Time11 

Source: USCIS metrics as of April 2016 

Green Cards Issued in Duplicate 

During the past year, USCIS inadvertently sent more than 6,200 duplicate 

Green Cards to customers. The most significant episode occurred in June 

2015, when more than 5,400 individuals received duplicate cards. This error 

was caused by a card production software update that inadvertently generated 

duplicates for a backlog of cards that were queued up for printing. Also in June 

2015, an additional 36 duplicate cards were mistakenly sent out after 

contractors were tasked to re-enter data for cases that had been stuck in 

CLAIMS 3. 

More recently, between March and May 2016, USCIS issued at least 750 

duplicate cards to its customers as a result of ELIS functionality or legacy data 

migration problems. The frequency and severity of these occurrences are being 

treated as high priority episodes by the OTC. In some cases, applicants paid 

the processing fee twice and received two cards. In another case, an applicant 

received Green Cards that belonged to two other applicants. 

Texas Service Center (TSC) personnel stated that a faulty sub-status field in 

ELIS has caused a number of duplicate cards to be produced from a single case 

number. Throughout the USCIS Immigrant Fee process, ELIS displays a case 

11 1,486,067, 1,807,400, and 2,081,233 Green Cards were produced and mailed in FY13, FY14, and 

FY15. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

sub-status to indicate when a card is ready to move forward to the USCIS 

production facility. In some cases, the system sub-status mistakenly indicated 

“Ready for Card Production” although the cards had previously been completed 

and sent forward for production. In several extreme cases in March 2016, five 

cards were produced per customer over the course of a single month. 

Additionally, 3 cards were produced for 12 individuals each, while 2 cards were 

produced for hundreds of individuals each, during the past year. 

During our visit to the TSC in April 2016, we also watched first-hand as 

personnel processed a case for an applicant in ELIS, where the case sub-status 

displayed “Ready for Card Production,” signaling it was ready to move forward 

for printing. But upon further investigation, multiple cards had already been 

printed and mailed to that particular applicant. TSC personnel estimated the 

system displays the wrong card status 10 percent of the time, which has 

caused their widespread reluctance to rely on ELIS data. The OTC was further 

investigating all such episodes during our audit in order to better understand 

the scope and cause for each. 

Inadequate USCIS Efforts to Address Green Card Errors 

USCIS has instituted several methods of addressing problems with Green Card 

errors. However, these methods — manual intervention, production controls, 

and system enhancements — have not proven adequate to ensure quality 

across the volume of cards produced and issued each year. More rigorous 

measures are needed to uphold the integrity of the production process and 

ensure that cards are consistently issued with accurate information to 

approved applicants. 

Manual Intervention and Scrutiny 

TSC’s process for identifying and addressing duplicate card issuance is 

primarily dependent upon manual intervention and scrutiny. For example, 

personnel cross-check numerous systems, such as ELIS and the Customer 

Profile Management System (CPMS), to research and verify each card in 

question. However, data in these systems are not linked and do not always 

match. According to TSC personnel, further analysis is required to identify 

duplicate card issuance because checking records in one system may only 

reveal whether a card was requested while another system must be checked to 

confirm whether a card was sent. 

In addition to the manual cross-checks, the OTC can generate an automated 

report to compare case numbers between ELIS and the CPMS as a means of 

identifying possible duplicate cards.12 When a duplicate is found, the OTC 

12 CPMS stores biographic and biometric Green Card data. 

www.oig.dhs.gov 9 OIG-17-11 
 

 

Source: OIG analysis of USCIS process 

Based on our assessment, these quality control steps are largely manual and 

cannot ensure quality across the roughly 2 million Green Cards produced and 

mailed each year. The approximately 19,000 cards issued in error from July 

2013 to May 2016 attest to this. Specifically: 

A. ELIS electronically confirms that the sub-status of each case is “Ready for 

Card Production” before the card is sent forward to EPMS. However, the 

effectiveness of this check may be negated when, as reported earlier, ELIS 

populates the wrong case status for an applicant. 

B. Each case is paused for a 72-hour period to allow time for USCIS personnel 

to take any corrective actions needed. TSC personnel said this step is 

beneficial, as it provides an opportunity to make changes, such as updates 

to customer addresses or card cancellations, if needed. However, this 

manual quality control step is inadequate to identify and address the 

increasing percentage of errors that occur in card production. 

C. EPMS electronically serves as a central hub to manage card production. 

EPMS conducts checks to reject cards with errors, such as blank data fields 

or photo images that are too light. EPMS also routes rejection messages to 

ELIS when duplicate receipt numbers are received, initiating a triage and 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

examines corresponding records in SMI to determine whether the card was 

already mailed. Although this is helpful, such processes to identify and address 

duplicate card issuance are after the fact, instead of preventative to keep the 

errors from occurring early in the process and before card production and 

mailing. 

Data Accuracy Controls 

USCIS’ Green Card quality control process is not effective. Quality control steps 

have been built into card production to alert personnel when actions are 

needed to correct data errors or cancel duplicates before card printing begins. 

The quality control steps are depicted by letters A–D in figure 5. 

Figure 5: Current Green Card Data Accuracy and Quality Control Process 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

inspection process to assess the situation. Again, this manual, timeconsuming process provides no assurance of catching all errors. 

D. A 48-hour hold is placed on each Green Card before it advances to the 

National Production System. This holding period serves as the final 

opportunity to stop card production and perform manual checks, as needed. 

System Enhancements 

The OTC has enhanced ELIS development and testing in efforts to prevent the 

same mistakes (i.e., incorrect and duplicate cards) from being repeated. Such 

enhancements have been highly reactive in nature. Specifically, in response to 

each episode, the OTC halted card production to research root causes for 

errors and improve system functionality. This included— 

	 issuing system configuration guidance for developers, such as step-bystep instructions to ensure toggle switches are configured correctly 

before an ELIS release is implemented; 

	 requiring that developers exercise greater caution and control and use 

version-controlled XML files to populate source decision databases. This 

is to help prevent a system release from changing case details or substatus if a case is already in card production; 

	 expanding testing to include additional checks to detect whether card 

production may be negatively affected by an ELIS release. OTC personnel 

said that they run about 60 “unit” and “integration” tests related to card 

production. They conduct “smoke” tests that are performed as part of the 

ELIS deployment pipeline.13 Live interface testing is also conducted to 

generate a virtual card and ensure there are no problems14; and 

	 ensuring more collaboration between the Operations and Maintenance 

Team and the Development Team to address episodes quickly. 

The OTC is evaluating additional mitigation strategies, such as developing an 

automated process in ELIS to add a real-time view of duplicate cards that may 

have been produced in other systems. An interface between ELIS, the SMI 

database, and CPMS is being added to provide greater visibility when duplicate 

cards are delivered and subsequently returned to USCIS. In addition, the OTC 

is collaborating with SCOPS to determine what additional quality checks are 

needed. Such strategies were still in the planning phase at the end of our audit 

fieldwork in June 2016. 

13 Unit testing is a software development process in which the smallest testable parts of a system are 

individually tested for proper operation. Integration testing is a phase in which individual modules are 

combined and tested as a group. A smoke test verifies that basic features work before they are deployed. 14 Interface testing ensures data transfers between various elements in the system are working correctly. 

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Episode Date Number of

Cards Affected

Number of Cards

Unaccounted For

1. Incorrect expiration dates July 2013 2,466 233

2. Incorrect names or date of birth May 2014 5,282 177

3. Incorrect “residence since” date Winter 2014 3,663 3,663

4. Duplicate cards issued June 2015 5,438 687

5. Duplicate cards issued June 2015 36 0

6. Incorrect expiration dates June 2015 772 772

7. Incorrect birth and “residence since” date September 2015 219 131

8. Incorrect photos November 2015 369 113

9. Duplicate cards issued March 2016 174 174

10. Duplicate cards issued April 2016 19 19

11. Duplicate cards issued April 2016 242 242

12. Duplicate cards issued May 2016 321 321

TOTALS 19,001 6,532 (34%)

                                                      

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Recommendations 

Recommendation 1: We recommend that the USCIS Director ensure ELIS 

design and functionality problems are corrected to prevent, to the extent 

possible, further Green Card processing errors. 

Recommendation 2: We recommend that the USCIS Director ensure 

development and implementation of the internal controls needed to ensure 

Green Card errors are identified and corrected early in the production process, 

prior to card issuance. 

Card Recall Efforts Unsuccessful Due to Lack of Consistency 

and Urgency 

USCIS efforts to recover improperly issued Green Cards have not been effective. 

USCIS conducts recalls for all episodes, but recall efforts lacked consistency 

and urgency. Further, due to inadequate tracking, USCIS had difficulty 

determining the exact number of cards returned in response to these efforts. 

Based on the information available, we found that roughly 6,532 (or 34 

percent) of the 19,001 Green Cards sent in error were unaccounted for, as 

listed in table 2. 

Table 2: Green Card Episodes and Recovery Data15 

Source: OIG analysis of USCIS data 

15 USCIS could not provide recall information for the episodes noted in italics. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Inconsistent and Untimely Recall Efforts 

To recover Green Cards issued in error following an episode, USCIS sends 

notices to affected individuals, providing instructions on how and where to 

return the cards. However, recall efforts conducted over the past 3 years lacked 

consistency. Each recall effort was managed by a designated office according to 

the risk level associated with the episode. USCIS offices did not employ a 

standardized process for how to contact affected individuals. After most 

episodes took place, USCIS made multiple attempts to contact the individuals 

by email and/or a series of hard-copy letters. In other cases, USCIS either 

made only one attempt to reach individuals or was not able to confirm whether 

any attempt was made. Without a uniform approach for conducting recall 

efforts across all offices or locations, the agency cannot ensure that impacted 

customers are receiving clear or timely instructions on how to return 

improperly issued cards. 

In addition, USCIS did not have a standard timeframe for how soon to issue 

recall letters after an episode occurred. There was no consistent management 

attention or urgency to initiating the recall actions. For instance, as of June 

2016, USCIS had not begun recall efforts for a number of episodes from the 

spring of 2016; these recall efforts were still in the early stages of planning. 

Further, although a letter for the July 2013 episode was drafted and mailed 

within 2 weeks, the letter for the September 2015 episode took 6 weeks to be 

mailed. Officials said the variance was due in part to the internal review 

process for issuing letters, which included multiple offices and individuals. For 

example, a designated lead in the OTC or another USCIS Program Office may 

be responsible for drafting a customer notice. Subsequently, all customer 

communications are vetted and reviewed by multiple agency stakeholders such 

as CSPED, SCOPS, and Counsel before final approval and signature. 

USCIS has a procedure to flag Green Cards sent out in error but did not 

consistently use it to prevent cards from being potentially misused by the 

recipients. When inappropriately issued cards are not recovered, the agency 

can flag the cards in TECS in order to alert CBP, ICE, and other law 

enforcement agencies of the potential for illegal activity or cards with incorrect 

information to be used for immigration and benefits-related purposes.16 This is 

referred to as a “TECS-hit” or establishing a TECS record. Per USCIS guidance, 

a TECS record must be created for all lost, stolen, or unrecoverable cards; 

however, USCIS could not confirm whether this procedure was followed after 

each episode.17 For example, USCIS officials stated TECS-hits were placed on 

16 TECS is the principal system used by officers at the border to assist with screening and determinations 

regarding admissibility of arriving persons. The system is owned by CBP. 

17 USCIS TECS Records Creation Standard Operating Procedure, dated June 13, 2013, identifies the 

process for issuing TECS-hits. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

unrecovered cards following the July 2013 and May 2014 episodes, but officials 

were not able to confirm this was done for the 10 later episodes. 

Further, USCIS did not have a standard timeframe for establishing TECS-hits. 

In one instance, TECS-hits were not requested until May of 2016 for an episode 

that took place 8 months prior, in September 2015. 

To the extent that USCIS does not successfully recover cards issued in error, 

individuals can potentially misuse the cards to obtain benefits or illegally stay 

in the country. For example, when USCIS issued roughly 2,500 conditional 

residence cards in 2013 with the wrong expiration dates, its Immigration 

Records and Identity Services Directorate became concerned that the 233 

unaccounted for cards are still with recipients indicating validity for 10 

years rather than 2 years as required. Even if a TECS-hit had been placed on 

these cards, they would still be in the physical possession of the individuals 

who had received them. 

Inadequate Tracking of Returned Cards 

USCIS could not provide an accurate number of cards recovered by the end of 

our audit fieldwork in June 2016. The agency struggled to obtain accurate 

counts because various recall efforts were led by different USCIS offices. In 

most cases, USCIS headquarters relied on regional service centers to maintain 

up-to-date inventories of cards returned to each location. For example, the TSC 

maintained spreadsheets to log each card as it was returned following at least 

three separate episodes between 2013 and 2015. TSC shared these 

spreadsheets with headquarters during each recall effort and provided us 

copies upon request during our audit. However, episodes managed by other 

offices or locations during that same timeframe did not have the same level of 

awareness. For example, the National Benefits Center was unable to provide 

information, stating further research was needed, for card recall attempts in at 

least two episodes that occurred in 2014 and 2015. 

Recommendations 

Recommendation 3: We recommend that the USCIS Director ensure 

development and implementation of a standard process for card recovery 

efforts. 

Recommendation 4: We recommend that the USCIS Director ensure 

development and implementation of a standard procedure for identifying and 

preventing unrecoverable cards from being used. 

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0

20,000

40,000

60,000

80,000

100,000

FY13 FY14 FY15

Number of Service Requests

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Recommendation 5: We recommend that the USCIS Director implement a 

centralized method to track and document Green Cards that are returned 

through recovery efforts. 

Missing Cards Attributable to Multiple Factors 

Over the last 3 years, USCIS received over 200,000 reports from approved 

applicants about missing cards. The number of cards sent to wrong addresses 

has incrementally increased since 2013 due in part to complex processes for 

updating addresses, ELIS limitations, and factors beyond the agency’s control. 

Increasing Service Requests Regarding Missing Green Cards 

Service requests initiated by USCIS customers claiming they did not receive 

Green Cards have steadily increased from 44,519 in FY 2013, to 67,247 in FY 

2014, and 92,645 in FY 2015. For the 3-year period, this represents an overall 

increase, from 3 percent to 4.5 percent, of the total Green Cards mailed each 

year. Figure 6 depicts this increase in service requests for missing cards, 

though it should be noted that some service requests may be duplicates if a 

customer contacted the agency more than once. 

Figure 6: Service Requests for Non-Delivered Cards 

Source: USCIS CSPED metrics as of June 2016 

USCIS leadership acknowledged that non-delivery cases, although a small 

percentage of total cards issued, are a significant concern. The agency 

admittedly cannot quantify the exact number of cards improperly delivered, 

since there is no way to detect fraudulent intent when a customer reports he or 

she did not receive a card. Customer complaints regarding the non-delivery of 

Green Cards have remained in USCIS’ top 10 most common service requests 

since FY 2011. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

The CIS Ombudsman has also experienced a steady increase in requests for 

assistance regarding the non-delivery of Green Cards.18 Typical requests 

include case assistance for adjudication delays and delivery problems. Whereas 

the Ombudsman received only 13 requests in FY 2013 from customers needing 

help, such requests increased to 83 in FY 2015, and had already climbed to 97 

for FY 2016 by June 2016. The Ombudsman’s 2016 Annual Report to Congress 

highlighted concerns with mail delivery failure and the potential consequences 

for USCIS customers, such as having to re-file an application and repay the 

application fee. 

Two USPS OIG studies regarding Green Cards reported missing by USCIS 

customers substantiate these findings. In October 2015, the USPS OIG 

researched 3,000 complaints of Green Cards missing or stolen between March 

2014 and October 2015 and found that all were marked as delivered. Its June 

2016 study of 18,000 cards reported missing between January and April 2016 

confirmed that over 95 percent were delivered as addressed. The USPS OIG 

concluded that although the reason for the high percentage of missing cards 

could not be attributed to one cause, more secure delivery methods should be 

used, such as signature confirmation or certified mail, where individuals are 

required to sign for the packages. 

Challenges to Ensuring Delivery of Secure Documents 

USCIS integrity is highly dependent on secure mailings to the correct addresses 

for eligible immigrants. The increases we found in cards sent to wrong 

addresses since 2013 can be attributed to complex processes for updating 

addresses, ELIS limitations, and factors beyond the agency’s control. 

Innovative measures are needed to help ensure proper delivery of immigration 

benefits documents. 

Address Change Process 

The Code of Federal Regulations requires that immigration documents be 

mailed directly to the applicant using the address provided, unless USCIS is 

notified of an address change.19 Applicants are required to report address 

changes within 10 days of moving.20 Efficient USCIS address change 

procedures are critical since immigrant applicants typically do not have 

permanent addresses. 

18 The USCIS Ombudsman is an independent, impartial resource that assists individuals with caserelated problems. 

19 8 Code of Federal Regulations 103. USCIS will also mail notices to an applicant’s legal representative, if 

authorized. 

20 8 Code of Federal Regulations 265 requires aliens to report a change of address within 10 days of 

moving. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

However, USCIS’ current process for updating a customer address is complex, 

involving multiple steps. A customer contacts USCIS to initiate the process, but 

then faces numerous options for submitting a change of address. The most 

common options are submitting an address change form, known as an AR-11, 

either online or by mail; calling the National Customer Service Center; or 

visiting a USCIS field office in person. Submitting an address change may be 

further complicated if the customer has pending or recently approved 

immigration benefit applications in process, requiring additional steps to 

ensure the address changes are captured on those other applications as well. 

The new address must be documented in several non-integrated USCIS 

systems containing customer information, including the Service Request 

Management Tool and CPMS. The update also must be separately entered into 

ELIS, the primary application for processing Green Cards. 

ELIS Limitations 

The ELIS design makes it difficult for TSC personnel to enter address changes 

quickly enough to keep up with customer demand. The TSC monthly processes 

an average of 50,000 cases, each of which needs address confirmation before 

mailing. Because ELIS lacks the capability to easily update addresses, USCIS 

personnel must enter entirely new addresses into the system when customers 

request address changes. Service center personnel stated that entering new 

addresses each time there is an update is a burdensome process, as it entails 

13 distinct steps. The TSC submitted a system enhancement request in 

December 2015 to reduce the number of steps, but this had not yet been 

implemented as of June 2016. TSC personnel stated this has resulted in a high 

number of cards mailed out before address changes are completed. 

The TSC personnel also stated ELIS does not always accurately display address 

information, often eliminating or cutting off critical elements such as 

apartment numbers due to field character limitations. If an address is 

truncated, clerks sometimes enter the service center address for delivery to 

avoid further issues. In other words, the clerks address the cards to themselves 

in efforts to keep the cases moving and prevent the cards from being misdelivered until they can determine how to correct the problems and direct the 

cards to the legitimate recipients. As a further complication, ELIS does not 

automatically default to the most recent address in its case history. Unless a 

box is checked, clerks cannot easily determine which of the addresses listed in 

the system has become the current primary address. 

After a card enters production, an address update can sometimes be 

accomplished during the 72-hour hold before printing and mailing, but only by 

certain individuals with the appropriate case access level. This hold is the final 

opportunity for USCIS personnel to take any corrective actions needed before 

card printing. Once the 72-hour window expires, all update actions are locked. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

As of April 2016, the number of TSC personnel who could change addresses 

during the hold period was less than two dozen. This was not enough staff to 

cover the high volume of address change requests for all USCIS documents 

each month at the TSC. 

Customers can update their profile pages in ELIS. Given the ELIS design, 

however, there is no electronic mechanism in place to verify the identity of 

whoever accesses the system to request the address change.21 Instead, as a 

security measure, USCIS will only mail a Green Card to the United States 

address an applicant provides to a Department of State consular officer or a 

CBP officer at a port of entry. For more than 2 years, the OTC has been 

working to provide a remote identity-proofing capability that will allow 

immigrants to securely change their addresses in ELIS through an automated 

verification process. OTC officials hoped to add this functionality to ELIS in 

July 2016, but as of August 2016 this enhancement had not been deployed. In 

the meantime, CSPED personnel sought to raise awareness by issuing public 

reminders about how to update an address if an applicant moves after arriving 

in the United States. The reminder messages are displayed on the monitors in 

USCIS field office waiting rooms, on the USCIS website, and in USCIS 

Immigrant Fee handouts. 

Other Factors 

The increasing number of missing cards may also be attributed to factors 

beyond the agency’s control. In some cases, customers fail to report their new 

addresses to USCIS or may not do so in a timely manner. External events — 

including mailbox theft, misrouted mail, mail delivered to incorrect locations, 

or mail intercepted by co-located family or friends — may also thwart card 

delivery to the legitimate applicants. In such cases, the onus is on the 

customer or the Postal Service to ensure proper deliveries. 

Additional Improvements Needed 

USCIS has struggled to manage these card delivery issues for some time. 

During the past year, USCIS officials have weighed a number of alternative 

delivery options, including signature confirmation, hold for pickup, and 

certified mail. In April 2016, the USCIS Senior Policy Council decided to test 

the hold for pickup option, which entails leaving cards at a Post Office for 

customers to collect them. CSPED plans to pilot this program for 6 months in 

2017. USCIS leadership favored this option because it provides additional 

signature and tracking information at no additional cost to the customer. 

21 Office of Management and Budget Memorandum M-04-04, E-Authentication Guidance for Federal 

Agencies, December 16, 2003. See also the National Institute of Standards and Technology Special 

Publication 800-63-2, August 2013. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

CSPED is also hoping to improve the address change process on the USCIS 

website. Specifically, the office plans to include USPS Address Verification for 

customers who submit address changes online. This involves the use of 

Address Verification software, which corrects spelling and formatting errors 

and ensures addresses are entered in the standard USPS format. 

Recommendations 

Recommendation 6: We recommend that the USCIS Director complete and 

implement identity-proofing capability to enable customers to submit address 

changes online in ELIS. 

Recommendation 7: We recommend that the USCIS Director evaluate the 

costs and benefits of using USPS’ Signature Confirmation as an alternative 

secure method for delivering Green Cards to applicants. 

Improperly Issued Green Cards Increase Risks, Workload, and 

Costs 

Improperly issued Green Cards can pose significant risks and burdens for the 

agency. Errors can result in approved applicants unable to obtain benefits, 

maintain employment, or prove lawful immigration status. In the wrong hands, 

Green Cards may enable terrorists, criminals, and illegal aliens to remain in 

the United States and access immigrant benefits. Responding to card issuance 

errors has also resulted in additional workload and corresponding costs, as 

USCIS spent just under $1.5 million to address card-related customer inquiries 

in FY 2015 alone. 

Denied Benefits for Approved Applicants 

Green Cards issued with incorrect personal information can have severe 

consequences for applicants who have become lawful permanent residents. 

Individuals use Green Cards to prove identity when applying for public 

benefits, such as drivers’ licenses or Social Security cards. The applicant’s 

eligibility is verified when the card is scanned and cross-checked against 

databases such as E-Verify or the Systematic Alien Verification for 

Entitlements program.22 Green Cards issued with the wrong name, birthdate, 

or photo could create confusion for Federal, state, and local agencies that 

22 E-Verify is an Internet-based system that compares information from an employee's Form I-9, 

Employment Eligibility Verification, to data from U.S. Department of Homeland Security and Social 

Security Administration records to confirm employment eligibility. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

administer benefits.23 Recipients possessing such cards could experience 

denial of benefits or possible card confiscation with accusations of fraudulent 

intent. This creates unnecessary hardship for the applicant who must reapply 

for a corrected card. 

When cards are missing or not properly delivered, applicants may be unable to 

obtain or renew driver’s licenses, Social Security cards, employment without 

interruption, or authorization to exit and re-enter the United States. In such 

cases, approved applicants may not be able to exercise their rights as lawful 

immigrants. 

National Security Risks 

Green Cards issued in error can pose national security risks. Thousands of 

cards issued with incorrect information or in duplicate remain unaccounted 

for, creating opportunities for exploitation by individuals with malicious intent. 

For instance, Green Cards that fall into the wrong hands may enable illegal 

immigrants to remain in the United States and demonstrate legal residence 

status to employers. The cards may be used to obtain various public benefits 

such as Social Security, Medicare, Veterans’ assistance, and government 

grants. Card holders might secure loans to purchase cars, homes, and travel. 

Drivers’ licenses, firearms, and concealed handgun licenses may be issued to 

card holders in certain states without restrictions. 

Officials within CBP’s Fraudulent Document Analysis Unit confirmed that there 

is a huge black market demand for legal documentation such as Green Cards. 

Such credentials can be used by imposters to reside in the United States or 

access other individuals’ benefits. Hundreds of imposter cases are recorded 

each year, accounting for over 80 percent of all Green Card fraud-related cases. 

CBP recorded over 4,600 cases of imposter Green Cards between 2013 and 

2015. 

Additional Workload and Costs 

When Green Cards are not properly delivered, the agency incurs additional 

workload and costs that could have been avoided. Managing the day-to-day 

activities to address each Green Card episode has typically entailed assembling 

a “Tiger Team” comprised of up to 4 dozen personnel from across multiple 

program offices and locations to deal with the widespread implications of the 

card errors. For example, team members worked together to locate customer 

contact information, draft recall notices, process and track returned cards, and 

23 Such as the U.S. Department of Housing and Urban Development, Social Security Administration, 

Transportation Security Administration, state-level Departments of Education, Health, and Motor 

Vehicles, and local social services. 

www.oig.dhs.gov 20 OIG-17-11 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

process applications for replacement cards. These efforts required several 

weeks or months to complete all relevant tasks. 

The increasing number of returned cards also creates additional work for 

individual service center personnel. Handling returned cards at the TSC was 

previously a collateral duty; it now requires 8 employees as over 30,000 Green 

Cards were returned to that facility in FY 2015. Each returned card requires a 

number of specific personnel actions, such as filing the card and logging the 

card as received in the inventory tracking spreadsheet. Personnel must look up 

each customer case to determine whether a new mailing address has been 

received since the original card was issued. In addition, each time a customer 

issues a complaint that a card was not received, service center personnel must 

search through drawers of returned cards to try to locate the one in question. 

At the time of our visit in April 2016, the TSC had over 15,000 returned cards 

in its possession. 

Further, CSPED addresses thousands of customer inquiries every month 

regarding non-delivery of Green Cards, soliciting the efforts of multiple USCIS 

personnel to research and manage each case. Customers may make inquiries 

online or by phone. For example, there are three possible levels of assistance 

for customers who call the National Customer Service Center and require help 

beyond the automated navigation menu. First, a live customer service 

representative will attempt to resolve the inquiry. If resolution is not reached, 

the service request is forwarded to another USCIS office, or routed to a USCIS 

officer with access to USCIS systems. As a final resort, calls may be escalated 

to a supervisory USCIS officer possessing the ability to contact other USCIS 

offices to obtain help in addressing issues that require immediate or direct 

assistance. 

The associated cost of dealing with these customer inquiries has significantly 

increased over the last few years. Specifically, the cost to USCIS for receiving 

and responding to non-delivery service requests nearly doubled from $780,267 

in FY 2013 to $1,488,082 in FY 2015. CSPED indicated the approximate cost 

to respond to a typical service request regarding an undeliverable secure 

document is between $10.85 and $14.46. We used the lower estimate of $10.85 

to illustrate these costs in figure 7. 

www.oig.dhs.gov 21 OIG-17-11 
 

 

$700,000

$900,000

$1,100,000

$1,300,000

$1,500,000

FY13 FY14 FY15

Cost of Service Requests

	 

	 

	 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Figure 7: Cost for Card Delivery Service Requests, FY 2013–2015 

Source: USCIS CSPED Metrics as of June 2016 

Until USCIS takes the steps needed to prevent card issuance errors, the 

upward trend in agency costs, as well as the risks to applicants and national 

security, is only likely to continue. 

OIG Analysis of USCIS Comments 

We obtained written comments on a draft of this report from the Director of 

USCIS. We have included a copy of the comments in their entirety in appendix 

B. 

In the comments, the USCIS Director appreciated the OIG acknowledging that 

the number of Green Cards containing errors actually represents a very small 

percentage of the total number of Green Cards issued by the agency each year. 

Also, the Director recognized the importance of further reducing these errors to 

the fullest extent possible and expressed commitment to improving USCIS 

processes and systems to accomplish that goal. 

The USCIS Director concurred with all of our recommendations. We reviewed 

the Director’s comments, as well as the technical comments previously 

submitted under separate cover, and made changes to the report as 

appropriate. Following is our evaluation of the Director’s general comments, as 

well as his response to each recommendation in the draft report provided for 

agency review and comments. 

OIG Response to General Comments: 

	 Regarding the Green Cards that were produced with inaccurate 

information or in duplicate, the Director emphasized that the individuals 

who received those cards were lawful permanent residents and were 

entitled to Green Cards. Therefore, while there may have been errors with 

data on the cards or issuance of duplicate cards, it is not precise to 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

indicate that USCIS inappropriately issued Green Cards. In addition, the 

Director stated that it is in the best interest of the individuals who 

received cards with data errors to follow specific USCIS procedures to 

return and replace those cards. Individuals who received multiple cards 

should either return the duplicate cards to USCIS or keep them safe to 

protect against identity theft. The Director stated that the inference that 

a substantial number of these recipients might put their identities at risk 

by misusing the cards is questionable. 

We disagree with the Director’s assertion. To the extent that USCIS does 

not successfully recover cards issued in error, improper recipients can 

potentially misuse the cards to obtain benefits or stay in the country 

illegally. For example, as stated in our report, when USCIS issued 

roughly 2,500 conditional residence cards in 2013 with the wrong 

expiration dates, its Immigration Records and Identity Services 

Directorate became concerned that 233 unaccounted for cards, 

indicating validity for 10 years rather than 2 years as required, were still 

with recipients. Even if a TECS record had been established to flag these 

cards, the cards would remain in the possession of the individuals who 

had received them. Further, as we state in this report, officials within 

CBP’s Fraudulent Document Analysis Unit confirmed that there is a 

black market demand for legal documentation such as Green Cards. 

	 The Director reiterated that the number of cards issued with errors is a 

very small percentage of the total number of Green Cards issued by the 

agency each year. However, the Director pointed out that figure 4 and the 

accompanying narrative indicating that the number of errors has 

“steadily increased” over the past 3 years could benefit from greater 

context. Specifically, the Director took issue with our excluding 2016 

data in figure 4, although we included it in tables 1 and 2. The Director 

asserted that including the 2016 data in figure 4 would have shown a 

precipitous drop in the Green Card error rate following FY 2015, 

attributable to USCIS’ efforts in this area. Moreover, the Director 

indicated that the error rate increase illustrated in figure 4 was very 

small, only about four one-thousandths of a percent of the total volume 

of cards issued. 

We did not include FY 2016 data in figure 4 because the full year’s worth 

of data was not available when we completed our audit fieldwork in June 

2016. We reviewed figure 4 and corrected the graphic to show that the 

error rate increased from one-tenth of a percent to approximately fivetenths of a percent from FY 2013 to FY 2015 although, as the Director 

asserted, this remained a very small percent increase of the total volume 

of cards issued. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

	 The Director clarified our finding throughout the report that USCIS 

mailed Green Cards to the “wrong address.” The Director stated that 

USCIS' standard practice is to mail Green Cards to the last known 

address on record, using a U.S. Postal Service that provides confirmation 

of delivery. The Director agreed that it is a challenge to have applicants 

timely provide address updates to USCIS for input to the appropriate 

systems as quickly as possible. As such, USCIS continues its outreach 

efforts to remind applicants of their responsibility to update their 

addresses, and to do so online when that capability becomes available. 

We state in our report that the increase in cards sent to the wrong 

addresses since 2013 may be attributed to factors beyond USCIS’ 

control, such as applicants failing to report changes of address. We also 

recognize that external events, such as mailbox theft, misrouted mail, 

mail delivered to incorrect locations, or mail intercepted by co-located 

family or friends may also thwart card delivery to the legitimate 

applicants. Without up-to-date address information, the Postal Service 

cannot ensure proper deliveries. To safeguard the integrity of the Green 

Card program, we believe it is incumbent upon USCIS to pursue every 

measure possible to ensure secure mailings to eligible immigrants. 

	 The Director opined that our report statement that “over 200,000 of the 

cards recorded as delivered during the last 3 years were reported by 

customers as missing” does not take into consideration that the number 

of calls does not equate to the number of missing cards. He explained 

that many applicants call multiple times, and some receive their cards 

after calling the National Customer Service Center. Further, the Director 

stated that a number of those calls may reflect instances in which no 

card was sent, or the card sent was returned by the U.S. Postal Service 

to USCIS. 

During our audit, USCIS officials admittedly could not quantify the exact 

number of cards improperly delivered. Nonetheless, we have revised our 

report to state that “over the last 3 years, USCIS received over 200,000 

reports from approved applicants about missing cards” instead of citing 

200,000 cards as missing. 

	 The Director took issue with our draft report statement that unrecovered 

cards pose potential national security risks and opportunities for 

exploitation by individuals with malicious intent. The Director countered 

that the Green Cards that USCIS issues are highly tamper resistant with 

three layers of security features. As such, a card would need to not only 

fall into the hands of someone with malicious intent, but also with a 

physical resemblance to the individual for whom the card was intended. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

We acknowledge in our report that Green Cards contain numerous builtin security features designed to prevent fraud. However, we stand firm in 

our position that unrecovered cards create potential national security 

risks and opportunities for exploitation. As we stated in our report, 

officials within CBP’s Fraudulent Document Analysis Unit confirmed that 

there is a demand for legal documentation such as Green Cards. 

Hundreds of imposter cases are recorded each year, accounting for over 

80 percent of all CBP Green Card fraud-related cases. For example, CBP 

recorded over 4,600 cases of imposter Green Cards between 2013 and 

2015. 

	 The Director stated that whenever USCIS identifies instances of issuance 

of duplicate cards, cards with incorrect information, or cards not received 

by the intended recipient, USCIS takes steps to render the card invalid in 

the appropriate DHS systems. Therefore, anyone who checks against 

USCIS systems to verify an individual's status would receive information 

that the card is invalid. Invalidated cards cannot be used to seek 

immigration benefits because USCIS conducts biometric checks and 

validates the applicant's eligibility at the time the new benefit request is 

made. Nonetheless, the Director advised that USCIS will review the 

possibility of expanding this process of invalidating cards to include 

instances where individuals complain about missing cards. 

In our report, we discussed that USCIS did not consistently follow its 

process to flag Green Cards sent out in error. As a result, USCIS was 

unable to certify that no missing cards were potentially misused by 

recipients. Further, USCIS did not have a standard timeframe for 

invalidating cards issued in error. In one instance, 8 months passed 

before USCIS took steps to invalidate cards issued in error. We believe 

the Director’s plan to potentially expand this process may be beneficial. 

Response to Report Recommendations: 

In the formal written comments, the Director concurred with all of our 

recommendations. Following is a summary of USCIS management’s response 

to each recommendation and our analysis. 

Recommendation 1: Ensure ELIS design and functionality problems are 

corrected to prevent, to the extent possible, further Green Card 

processing errors. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Management Comments 

The Director concurred with recommendation 1, stating that USCIS' OTC has 

built-in controls to mitigate issuing cards with inaccurate information in the 

new ELIS system. Within OTC, work was underway to create alerts and queries 

with other systems in the workflow to assist in identifying duplicate cards 

before the duplicates were created or sent. The Director estimated that these 

actions would be completed by December 30, 2016. 

OIG Analysis 

We agree that the plans and actions described above to improve system 

controls and information sharing between systems in the Green Card 

processing workflow should help to prevent further errors. This 

recommendation will remain open and resolved until USCIS provides evidence 

it has completed the steps described above to prevent further Green Card 

processing errors. 

Recommendation 2: Ensure development and implementation of the 

internal controls needed to ensure Green Card errors are identified and 

corrected early in the production process, prior to card issuance. 

Management Comments 

The Director concurred with recommendation 2, stating that OTC was working 

to improve ELIS testing, both automatic and exploratory, and build in stricter 

regression testing to improve identification and correction of errors. The 

Director estimated that these actions would be completed by April 28, 2017. 

Further, the Director stated that USCIS has implemented a number of internal 

controls in CLAIMS 3 to prevent Green Card issuance errors. Specifically, after 

a card request has been submitted to the National Production System through 

the Enterprise Print Management Service (EPMS), no changes can be made to 

the request. CLAIMS 3 returns a “duplicate” request error to the adjudicator if 

the same case number is submitted to the production queue within a 72-hour 

timeframe. To prevent duplicate card creation due to systematic issues, each 

card request has a specific transaction identification number, which returns an 

error if the same number is submitted multiple times. Once a card has been 

produced, a duplicate card cannot be requested in CLAIMS 3 without a twoperson authorization for production. All USCIS authorized personnel can 

access the card queue system to determine the current status of a card 

request. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

OIG Analysis 

We agree that the actions described above to improve testing and build in 

stricter regression testing should help ensure Green Card errors are identified 

and corrected early in the production process. This recommendation will 

remain open and resolved until USCIS provides evidence that it has developed 

and fully implemented all testing and internal controls needed to ensure Green 

Card errors are identified and corrected prior to card issuance. 

Recommendation 3: Ensure development and implementation of a 

standard process for card recovery efforts. 

Management Comments 

The Director concurred with recommendation 3, stating that USCIS' CSPED 

will lead a review of previous end-to-end processes for card recovery efforts and 

lessons learned to develop a Standard Operating Procedure for these efforts. 

The Director estimated that these actions will be completed by January 31, 

2017. 

OIG Analysis 

The plans described to develop a standard operating procedure for card 

recovery efforts satisfy the intent of the recommendation. This 

recommendation will remain open and resolved until USCIS provides 

evidence that it has developed and implemented a standard process for 

card recovery efforts. 

Recommendation 4: Ensure development and implementation of a 

standard procedure for identifying and preventing unrecoverable 

cards from being used. 

Management Comments 

The Director concurred with recommendation 4, again citing CSPED’s plans to 

lead a review of end-to-end processes and lessons learned for card recovery 

efforts and develop a Standard Operating Procedure by January 31, 2017. 

OIG Analysis 

We agree with USCIS’ plans as described to develop a standard operating 

procedure for card recovery efforts. USCIS should ensure this procedure also 

includes a method for identifying and preventing unrecoverable cards from 

being used. This recommendation will remain open and resolved until USCIS 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

provides evidence that it has developed and implemented a standard procedure 

for identifying and preventing unrecoverable cards from being used. 

Recommendation 5: Implement a centralized method to track and 

document Green Cards that are returned through recovery efforts. 

Management Comments 

The Director concurred with recommendation 5, agreeing that a centralized 

method to track and document card recovery efforts would be beneficial. 

CSPED will explore how tracking will occur and where it would be best situated 

within USCIS. The Director estimated that these actions will be completed by 

March 31, 2017. 

OIG Analysis 

The plans described to establish a centralized method to track and document 

card recovery efforts satisfy the intent of the recommendation. This 

recommendation will remain open and resolved until USCIS provides evidence 

that it has implemented a centralized method to track and document Green 

Cards that are returned through recovery efforts. 

Recommendation 6: Complete and implement identity-proofing capability 

to enable customers to submit address changes online in ELIS. 

Management Comments 

The Director concurred with recommendation 6, stating that USCIS has 

already developed an online process to remotely verify a new immigrant's 

identity. The Director explained that this process provides additional security 

by ensuring that only the applicant can access and update his or her 

information in an online USCIS account. The first phase of this process began 

on July 12, 2016. USCIS is piloting this capability and plans to implement it 

fully by January 31, 2017. 

OIG Analysis 

We agree that USCIS’ plans to implement an online process may improve its 

ability to remotely verify a new immigrant's identity. This recommendation will 

remain open and resolved until USCIS provides evidence that it has fully 

implemented identity-proofing capability to enable all customers to submit 

address changes online in ELIS. 

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Department of Homeland Security 

Recommendation 7: Evaluate the costs and benefits of using USPS’ 

Signature Confirmation as an alternative secure method for delivering 

Green Cards to applicants. 

Management Comments 

The Director concurred with recommendation 7. He stated that, in addition to 

pursuing other options, USCIS previously conducted an in-depth analysis of 

the costs and benefits of using USPS' Signature Confirmation as a secure 

method for delivering Green Cards to applicants. The Director estimated that 

corrective actions will be completed by June 30, 2017. 

OIG Analysis 

USCIS’ plans for reviewing alternative secure methods for delivering Green 

Cards are a step in the right direction. This recommendation will remain open 

and resolved until USCIS provides evidence that it has evaluated the costs and 

benefits of using USPS’ Signature Confirmation as an alternative secure 

method for delivering Green Cards to applicants. 

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Appendix A 

Objective, Scope, and Methodology 

As part of our ongoing responsibilities to assess the efficiency, effectiveness, 

and economy of departmental programs and operations, we audited USCIS' 

processes and procedures for printing and mailing Green Cards to applicants. 

Specifically, our objective was to assess the extent to which USCIS has 

inappropriately issued Green Cards, evaluated its actions to recover the cards, 

and assessed its actions and plans to prevent similar incidents in the future. 

We researched and reviewed Federal laws and agency guidance, policies, and 

procedures related to Green Card eligibility, production, and distribution. We 

obtained documents, congressional testimony, and news articles regarding 

Green Cards. Additionally, we reviewed published Government Accountability 

Office and DHS OIG reports to identify prior findings and recommendations. 

We used this information to establish a data collection approach that consisted 

of interviews with relevant stakeholders, focused information gathering, 

documentation analysis, selected site visits, and system demonstrations to 

accomplish our inquiry objectives. 

We held more than 30 meetings and participated in teleconferences with USCIS 

staff at headquarters and at field offices to learn about Green Card processing. 

At headquarters, we met with representatives of the Office of Transformation 

Coordination, Management Directorate, Office of Intake and Document 

Production, Document Management Division, Customer Service and Public 

Engagement Directorate, Fraud Detection and National Security, Office of 

Information Technology, Field Operations Directorate, and Service Center 

Operations Directorate. We interviewed USCIS officials, including the Office of 

Transformation Coordination Chief, Office of Management Associate Director, 

Field Operations Directorate Acting Associate Director, Field Operations 

Directorate Deputy Associate Director, Service Center Operations Associate 

Director, and Customer Service and Public Engagement Deputy Associate 

Director to discuss their roles and responsibilities related to Green Card 

processing. We also held meetings and participated in teleconferences with 

individuals from the USCIS Ombudsman’s Office, CBP, ICE, and USPS. 

We visited USCIS Service Centers in Texas and Virginia in April and May 2016 

respectively. We also conducted a teleconference with the National Benefits 

Center. During our field visits, we met with executive personnel, Section Chiefs, 

Immigration Services Officers, and ELIS end-users to understand system 

requirements and use in the field. We discussed USCIS’ Green Card processes, 

IT environment, user involvement, system challenges, and communication with 

headquarters and collected supporting documentation. 

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Department of Homeland Security 

We conducted this performance audit between April and June 2016 pursuant 

to the Inspector General Act of 1978, as amended, and according to generally 

accepted government auditing standards. Those standards require that we plan 

and perform the audit to obtain sufficient, appropriate evidence to provide a 

reasonable basis for our findings and conclusions based upon our audit 

objectives. We believe the evidence obtained provides a reasonable basis for our 

findings and conclusions based upon our audit objectives. 

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Appendix B 

Agency Comments to the Draft Report 

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Department of Homeland Security 

Appendix C 

Office of IT Audits Major Contributors to This Report 

Kristen Bernard, Director 

Kristen Fogarty, Audit Manager 

Swati Nijhawan, Senior Program Analyst 

Gregory Flatow, Program Analyst 

Sagen Gearhart, Program Assistant 

Richard Saunders, Referencer 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix D 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

Deputy Chiefs of Staff 

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

Director, USCIS 

Deputy Director, USCIS 

Liaison, USCIS 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees 

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ADDITIONAL INFORMATION AND COPIES 

To view this and any of our other reports, please visit our website at: www.oig.dhs.gov. 

For further information or questions, please contact Office of Inspector General Public Affairs 

at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov. Follow us on Twitter at: @dhsoig. 

OIG HOTLINE 

To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click on the red 

"Hotline" tab. If you cannot access our website, call our hotline at (800) 323-8603, fax our 

hotline at (202) 254-4297, or write to us at: 

Department of Homeland Security 

Office of Inspector General, Mail Stop 0305 

Attention: Hotline 

245 Murray Drive, SW 

Washington, DC 20528-0305