Information Collection

Electronic Diversity Visa Entry Form

IC 15041 under ICR 201908-1405-006 · OMB 1405-0153.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0153 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-5501 Electronic Diversity Visa Entry Form	Form and Instruction
DS-5501 Electronic Diversity Visa Entry Lottery Form Final DS-5501 Screenshot.docx www.dvlottery.state.gov	Form and Instruction
Justification for non-substantive change.docx Justification for non-substantive change	IC Document
CCR 96771 Changes.docx Change #1	IC Document
CCR 96772_Changes.docx Change #2	IC Document

IC Title:

Electronic Diversity Visa Entry Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR 42.33

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-5501	Electronic Diversity Visa Entry Lottery Form	Final DS-5501 Screenshot.docx	www.dvlottery.state.gov	Yes	Yes	Fillable Fileable Signable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14,589,023

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	PreApproved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	14,589,023	3,516,623	11,072,400
Annual IC Time Burden (Hours)	7,294,512	1,758,312	5,536,200
Annual IC Cost Burden (Dollars)	72,945,115	17,583,115	55,362,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for non-substantive change	Justification for non-substantive change.docx	07/25/2017
Change #1	CCR 96771 Changes.docx	07/25/2017
Change #2	CCR 96772_Changes.docx	07/25/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.