21.10.

2012

Electronic Diversity Visa Lottery

Applicant Entry System v10.00.00

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

ELECTRONIC DIVERSITY VISA ENTRY FORM

Submission Confirmation: Entry Received

Success!

Your entry for the 2014 Diversity Visa Lottery program was received on Sunday, October 21, 2012 at 11:31:54 AM EST. Please do NOT close this window until you have printed this confirmation page or made a record of your Confirmation Number. Entrant Name: Confirmation Number: Year of Birth: Digital Signature: ORLOWSKA, KAROLINA MARZENA 20141VSUIDTVDA3S 1990 F9ECF4D778D17988B70D7D2709141353BCCE6A99

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.

PA PERWORK REDUCTION A CT: Public re porting burde n for this colle ction of inform ation is e stim ate d to ave rage 30 m inute s pe r re sponse , including tim e re quire d for se arching e x isting data source s, gathe ring the ne ce ssary docum e ntation, providing the inform ation and/or docum e nts re quire d, and re vie wing the final colle ction. You do not have to supply this inform ation unle ss this colle ction displays a curre ntly valid O MB control num be r. If you have com m e nts on the accuracy of this burde n e stim ate and/or re com m e ndations for re ducing it, ple ase se nd the m to: A/GIS/DIR , R oom 2400 SA-22, U.S. De partm e nt of State , W ashington, DC 20522-2202. CONFIDENTIA LITY STA TEMENT: AUTHO R ITIES: The inform ation ask e d for on this form is re que ste d pursuant to Se ction 222 of the Im m igration and Nationality Act. Se ction 222(f) provide s that the re cords of the De partm e nt of State and of diplom atic and consular office s of the Unite d State s pe rtaining to the issuance and re fusal of visas or pe rm its to e nte r the Unite d State s shall be conside re d confide ntial and shall be use d only for the form ulation, am e ndm e nt, adm inistration, or e nforce m e nt of the im m igration, nationality, and othe r laws of the Unite d State s. C e rtifie d copie s of such re cords m ay be m ade available to a court provide d the court ce rtifie s that the inform ation containe d in such re cords is ne e de d in a case pe nding be fore the court. PUR PO SE: The U.S. De partm e nt of State use s the facts you provide on this form prim arily to de te rm ine your classification and e ligibility for a U.S. im m igrant visa. Individuals who fail to subm it this form or who do not provide all the re que ste d inform ation m ay be de nie d a U.S. im m igrant visa. Although furnishing this inform ation is voluntary, failure to provide this inform ation m ay de lay or pre ve nt the proce ssing of your case . R O UTINE USES: If you are issue d an im m igrant visa and are subse que ntly adm itte d to the Unite d State s as an im m igrant, the De partm e nt of Hom e land Se curity will use the inform ation on this form to issue you a Pe rm ane nt R e side nt C ard, and, if you so indicate , the Social Se curity Adm inistration will use the inform ation to issue a social se curity num be r. The inform ation provide d m ay also be re le ase d to fe de ral age ncie s for law e nforce m e nt, counte rte rrorism and hom e land se curity purpose s; to C ongre ss and courts within the ir sphe re of jurisdiction; and to othe r fe de ral age ncie s who m ay ne e d the inform ation to adm iniste r or e nforce U.S. laws.

https://www.dvlottery.state.gov/application.aspx

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21.10.2012

Electronic Diversity Visa Lottery

Consular A ffairs Main Page | Welcome Page | Top of Page This site is m anage d by the Bure au of C onsular Affairs, U.S. De partm e nt of State . Ex te rnal link s to othe r Inte rne t site s should not be construe d as an e ndorse m e nt of the vie ws containe d the re in.

https://www.dvlottery.state.gov/application.aspx

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