U.S.

Department of State Electronic Diversity Visa

Bureau of Consular Affairs Applicant Entry System:
12.8

 Help

Electronic Diversity Visa Entry Form OMB Control Number:

1405-0153

Form:
DS-5501

Expires:
08/31/2022

Estimated Burden:
30 minutes

Part One - Entrant Information

1. Name

Last/Family Name First Name Middle Name

APELLIDOS SEGUN PASAPORTE PRIMER NOMBRE SEGUNDO NOMBRE

No First Name
No Middle Name

2. Gender

Male
Female

3. Birth Date

Month Day Year

mm dd yyyy

4. City Where You Were Born

Enter Birth City Only. Do not enter District/County/Province/State.

Birth City

CIUDAD DE NACIMIENTO, NO DISTRITO, NO PROVINCIA

Birth City Unknown

5. Country Where You Were Born

Select A Country... PAIS DE NACIMIENTO

6. Country of Eligibility for the DV Program

Your country of eligibility will normally be the same as your country of birth.
Your country of eligibility is NOT related to where you live.
If you
were born in a country that is not eligible for the DV program, please go to
Explanation of Country of Eligibility
to see if there is another
option available in your case.

Are you claiming eligibility based on the country where you were born?
Yes No
If not, you must enter the country from which you are claiming eligibility.
Select A Country...

7. Passport
In order to submit an entry for the Diversity Visa program, you must currently possess a valid, unexpired passport from

your country of nationality, unless exempt (see below). Please answer A or B.

A) Passport Information: DATOS SEGUN PASAPORTE

Name On Passport:

Last/Family Name First Name Middle Name

No First Name
No Middle Name

Passport Number: NUMERO DE PASAPORTE

Passport Expiration Date: FECHA DE EXPIRACION

Month Day Year

mm dd yyyy

Country/Authority of Issuance: PAIS DE ORIGEN

Select A Country...

B) Passport Exemption: NO LLENAR, ES PARA QUIENES LEGALMENTE NO TIENE PASAPORTE

I am not required to submit passport information because I am:

Stateless (no nationality)

A national of a Communist-controlled country, and unable to obtain a passport
from my government.
Unable to obtain a passport, and have received an individual waiver of

the passport requirement by the Secretary of Homeland Security or Secretary of State.

I understand that if it is later determined I am not exempt from the passport requirement, I may be disqualified from the Diversity Visa program.

8. Entrant
Photograph

Photographs must be submitted at the time of eDV entry. Photographs that do not comply with all specifications,
including but not limited to
recency of the photos (must be taken in the last six months), composition of the photos, and unacceptable backgrounds are
grounds for
disqualification of the entire entry. Any manipulation of photographs that alters the facial
characteristics is grounds for disqualification of the
entire entry. See examples on the
Photo Examples
page.

Please refer to the Instructions for the

2023
Diversity Immigrant Visa program (DV-2023) for
technical specifications and compositional
specifications for the digital image.

You will use one of the following methods to enter the image into eDV:

Take a new digital image.

Use a digital scanner to scan a recent photograph.

Link to Photo Instructions/Photo Examples page

Clicking the 'Choose New Photo' button will allow you to look for and
choose the file which is storing the photograph. Once chosen, the file
name and the
photo will display. If the photo is not correct, please click on the 'Choose New Photo'
button to choose a new file.

Choose New Photo

9. Mailing Address

a. In Care Of (optional)

b. Address Line 1
c. Address Line 2 (optional)

d. City/Town

e. District/County/Province/State

f. Postal Code/Zip Code

No Postal Code / Zip Code

g. Country

Select A Country...

10. Country Where You Live Today

Select A Country... PAIS DE RESIDENCIA

11. Phone Number

(optional)

12. E-mail Address

a. E-Mail Address (e.g. [email protected])

b. Confirm E-Mail Address

(NOTE: This e-mail address will be used to provide you

with additional information if you are selected.)

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

Primary school only

High School, no degree
High School degree
Vocational School
Some University Courses ALGUNOS CICLOS DE UNIVERSIDAD

University Degree UNIVERSIDAD COMPLETA

Some Graduate Level Courses

Master's Degree
Some Doctorate Level Courses
Doctorate 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://www.onetonline.org/
to see if your occupation qualifies) for a Diversity Visa.

14. What is your current marital status?

Unmarried SOLTERO

Married and my spouse is NOT a U.S.citizen or U.S. Lawful Permanent Resident (LPR) CASADO CON NO RESIDENTE AMAERICANO
Married and my spouse IS a U.S.citizen or U.S. Lawful Permanent Resident (LPR)
Divorced
Widowed
Legally Separated

Enter Spouse Information
Legal separation is an arrangement when a couple remain married but live apart,
following a court order. If you and your spouse are legally
separated, your spouse
will not be able to immigrate with you through the Diversity Visa program. You will
not be penalized if you choose to
enter the name of a spouse from whom you are
legally separated.

If you are not legally separated by a court order, you must include your spouse even if you plan to be divorced before you apply for the Diversity
Visa. Failure to list your eligible spouse is grounds for disqualification.

If your spouse is a U.S. citizen or Lawful Permanent Resident, do not list him/her in your entry.

15. Number of Children

NUMERO DE HIJOS MENORES DE 21

Children include all biological children, legally adopted children, and stepchildren who are unmarried and under the age of 21 on the date you
submit your entry. You must include all eligible children, even if they do not live with you or if they do not intend to apply for a Diversity Visa as
your derivative. Failure to list all eligible children is grounds for disqualification. If your child is a U.S. citizen or Lawful Permanent Resident, do
not list him/her in your entry.

Continue Cancel Entry

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: [email protected].

CONFIDENTIALITY STATEMENT:
The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. INA Section 222(f) provides that
visa issuance and refusal records 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 visa records may be made available to a court which certifies that the information contained in such records is
needed in a case pending before the court.

PRIVACY POLICY:
For information on the Department of State’s privacy policy, regarding the nature, purpose, use, and sharing of any Personally Identifiable Information (PII)
collected via this website please click here.

 travel.state.gov
 Welcome Page
 Top of Page

This site is managed by the Bureau of Consular Affairs, U.S. Department of State. External links to other Internet sites should
not be construed as an endorsement of the views
contained therein.