OMB Control Number: 1405-0153

Form: DS-5501
ELECTRONIC DIVERSITY VISA ENTRY FORM Expires: 05/31/2011
Estimated Burden: 30 minutes

Submission Confirmation: Entry Received

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Your entry for the 2012 Diversity Visa Lottery Program Lottery Entry Form was received on Monday, November 1, 2010
at 2:56:38 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: Senevirathne, SajithRanjeewa

Confirmation Number: 20122JPHHHNKFK5P
Year of Birth: 1983
Thank you for your entry for the 2012 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 using the internet. You may check back
at this link http://www.dvlottery.state.gov/ESC/ between May 1, 2011 and June 30, 2012 to determine whether your
entry was selected for further processing in the 2012 DV 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 Lottery.

PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average 30 minutes per respon
including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or doc
required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/
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 Im
and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the Unit
pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only
formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified co
such records may be made available to a court provided the court certifies that the information contained in such records is needed in a c
pending before the court. PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your cla
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 b
U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the process
case. ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Depa
Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Securi
Administration will use the information to issue a social security number. The information provided may also be released to federal agenci
enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other fe
agencies who may need the information to administer or enforce U.S. laws.

Consular Affairs Main Page | Top of Page

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

Top of Form
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OMB Control Number: 1405-0153

Form: DS-5501
ELECTRONIC DIVERSITY VISA ENTRY FORM Expires: 05/31/2011
Estimated Burden: 30 minutes

Submission Confirmation: Entry Received

Success!
Printer friendly version
Your entry for the 2012 Diversity Visa Lottery Program Lottery Entry Form was received on
Monday, November 1, 2010 at 2:56:38 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: Senevirathne, SajithRanjeewa
Confirmation Number: 20122JPHHHNKFK5P
Year of Birth: 1983
Thank you for your entry for the 2012 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 using the
internet. You may check back at this link http://www.dvlottery.state.gov/ESC/ between May
1, 2011 and June 30, 2012 to determine whether your entry was selected for further processing
in the 2012 DV 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 Lottery.
Bottom of Form

PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average 30 minutes per respon
including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or docu
required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/
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 Im
and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the Unite
pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only
formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified cop
such records may be made available to a court provided the court certifies that the information contained in such records is needed in a ca
pending before the court. PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your cla
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 b
U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the process
case. ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Depa
Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Securi
Administration will use the information to issue a social security number. The information provided may also be released to federal agencie
enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other fe
agencies who may need the information to administer or enforce U.S. laws.

Consular Affairs Main Page | Top of Page

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