ELECTRONIC DIVERSITY VISA ENTRY FORM
OMB Control Number: 1405-0153
Estimated Burden: 30 minutes
Submission Confirmation: Entry Received
Your entry for the 2014 Diversity Visa Lottery program was received on Sunday, October 28, 2012 at 12:56:29
AM EST. Please do NOT close this window until you have printed this confirmation page or made a record of your
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
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.
Year of Birth:
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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