Electronic Diversity Visa Lottery

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ELECTRONIC DIVERSITY VISA ENTRY FORM

OMB Control Number: 1405-0153
Form: DS-5501
Expires: 07/31/2013
Estimated Burden: 30 minutes

Submission Confirmation: Entry Received

Success!

Your entry for the 2014 Diversity Visa Lottery program was received on Wednesday, October 31, 2012 at 12:47:06 PM EST. Please do NOT close this window until you have printed this confirmation page or made a record of your Confirmation Number.

Entrant Name:	KANTSARA, VALERIY DMITRIEVICH
Confirmation Number:	2014276G86T1FI12
Year of Birth:	1959
Digital Signature:	3382A8FC3D80F506720D35F9E0DB386ADDEA6722

Thank you for your entry for the 2014 Diversity Visa Lottery.

Please either print this page or make a record of the confirmation number before closing this window. You will not be able to retrieve this number after you close this window.

You must retain your confirmation number in order to check your entry status via http://www.dvlottery.state.gov/ESC/ between May 1, 2013 and September 30, 2014 to determine whether your entry was selected for further processing in the 2014 Diversity Visa Lottery. You will be REQUIRED to enter your confirmation number in combination with other personal information in order to check on your entry status.

Selectees will not receive selectee notifications or letters by regular postal mail from the Kentucky Consular Center (KCC).

Do not submit additional Entry Forms with this person as the Primary Entrant! Multiple entries will disqualify the Entrant from participation in the 2014 Diversity Visa Lottery.

PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.

CONFIDENTIALITY STATEMENT: AUTHORITIES: The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for the formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of such records may be made available to a court provided the court certifies that the information contained in such records is needed in a case pending before the court. PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your classification and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be denied a U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing of your case. ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Department of Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for law enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federal agencies who may need the information to administer or enforce U.S. laws.

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