Form DS-4284 WHITE HOUSE TOURS REQUEST

OMB APPROVAL NO. 1405-0105
EXPIRATION DATE: xx-xx-xxxx
ESTIMATED BURDEN: 10 MINUTES*

U.S. Department of State

WHITE HOUSE TOURS REQUEST
EMBASSY INFORMATION
Embassy Contact Surname

Given Name

Requesting Contact Telephone Number

Extension

Contact Fax Number

Contact E-mail

Contact Cell Phone Number

TOUR INFORMATION
Requested date must be at least 7 days in advance and before 21 days from today. The date format must be MM-DD-YYYY, example : 02-02-2014
Request Date (mm-dd-yyyy)

Escort's Title

Escort's Surname

Escort's PID

Number of People (1-6)

Escort's Given Name

Parking Requested

Special Needs (If yes, explain below)

Describe Special Needs (Wheelchairs, etc.)

VISITOR SECURITY INFORMATION
Surname

Gender

Citizenship Status

Given Name

Date of Birth (mm-dd-yyyy)

Country of Citizenship

City you're staying in the U.S. (example: Atlanta)

Middle Initial

Country of Origin

Passport Number

State you're staying in the U.S. (example: Georgia)

PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time required for searching
existing data sources, gathering the necessary data, providing the information required, and reviewing the final collection. In accordance with 5 CFR
1320.5(b), persons are not required to respond to the collection of this information unless this form displays a currently valid OMB control number.
Send comments on the accuracy of this estimate of the burden and recommendations for reducing it to M/OFM, 3507 International Place NW,
Washington, DC 20008.
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations
of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions Act of 1982
(22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used by the U.S. Department of State (DOS) to adjudicate requests made by foreign
governments for White House tours.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Submission of information is voluntary; however, failure to provide any of the requested information may result in the denial of the
requested tour.

DS-4284
xx-2014