Electronic Diversity Visa Entry Form
OMB Control Number: 1405-0153Form: DS-5501Expires: 08/31/2020Estimated Burden: 30 minutes
Full name*
Last/Family name First name Middle name
Gender
Birth City*
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Улица, линия 2
Город Страна / Область
Почтовый Индекс
Birth Date*
Month Day Year
Country Where You Were Born*
Улица
Улица, линия 2
Город Страна / Область
Почтовый Индекс
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.
Улица
Улица, линия 2
Город Страна / Область
Почтовый Индекс
Entrant PhotographPhotographs 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 2021 Diversity Immigrant Visa program (DV-2021) 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 pageClicking 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 the file*
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Country Where You Live Today
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Улица, линия 2
Город Страна / Область
Почтовый Индекс
E-mail*
Phone Number
Area Code Phone Number
What is the highest level of education you have achieved, as of today?*
Primary school only High School, no degree High School degree University Degree
What is your current marital status?*
Unmarried Married and my spouse is NOT a U.S.citizen or U.S. Lawful Permanent Resident (LPR Married and my spouse IS a U.S.citizen or U.S. Lawful Permanent Resident (LPR) Divorced
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 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.