Electronic Diversity Visa Lottery

Applicant Entry Systemv10.00.00

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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

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Part One - Entrant Information

1. Name

a. Last/Family Name
Kantsara

b. First Name
Valeriy

c. Middle Name
Dmitrievich

2. Birth Date

March 17, 1959

3. Gender

Male

4. City Where You Were Born

Andreevka Kharkov region

5. Country Where You Were Born

Ukraine

6. Country of Eligibility for the DV Program

Ukraine

7. Entrant Photograph

(Photograph received)

8. Mailing Address

8a. In Care Of
8b. Address Line 1	Prospect Metallurgists,48
8c. Address Line 2
8d. City/Town	city of Alchevsk
8e. District/County/Province/State	Luhansk region
8f. Postal Code/Zip Code	94206
8g. Country	Ukraine
(NOTE: This is the address that will be used to notify you if you are selected.)

9. Country Where You Live Today

Ukraine

10. Phone Number

0380644246693

11. E-mail Address

d20088002d@gmail.com

12. What is the highest level of education you have achieved, as of today?

Master's Degree

You must have a minimum of a high school diploma reflecting the completion of a full course of study (vocation schools or equivalency degrees are not acceptable) or be a skilled worker in an occupation that requires at least two years of training or experience to qualify (visit http://online.onetcenter.org/ {this link will open in a new window} to see if your occupation qualifies) for a Diversity Visa.

13. What is your current marital status?

Married

Legal separation means that a court has formally declared that you and your spouse are legally separated. Legal separation means that your spouse would not be eligible to immigrate as your derivative.

14. Number of Children

Children include all biological children, legally adopted children, and stepchildren who are unmarried and under the age of 21 on the date that you submit your entry. Failure to include all children or inclusion of children who are not your biological children, legally adopted children, and stepchildren (regardless of whether they live with you and/or intend to apply for a visa as your derivative) is grounds for disqualification of the entire entry.

Legal Permanent Residents (LPR) and American Citizens should not be included.

Part Two - Derivatives

13. Spouse Name

a. Last/Family Name
Kantsara

b. First Name
Zoya

c. Middle Name
Ivanovna

13d. Birth Date

March 01, 1960

13e. Gender

Female

13f. City Where Spouse Was Born

Alchevsk

13g. Country Where Spouse Was Born

Ukraine

13h. Spouse Photograph

(Photograph received)

14. Child #1 Name

a. Last/Family Name
Kantsara

b. First Name
Valeriya

c. Middle Name
Valerievna

14d. Birth Date

June 03, 1993

14e. Gender

Female

14f. City Where Child Was Born

Alchevsk

14g. Country Where Child Was Born

Ukraine

14h. Child Photograph

(Photograph received)

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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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