DS-5537 JADE Act Questionnaire

OMB CONTROL NO. 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX

U.S. Department of State

JADE Act Questionnaire
• If you are unsure of the answer to a question, please provide a response to the best of your knowledge. For example,
if you are unsure of an exact date of birth, provide the year and month if you can recall them. U.S. Department of State
will consider all the information derived from the form in its entirety.
• Failure to answer every question will not necessarily preclude visa issuance, as the application is considered in its
entirety.
• If you believe a particular question does not apply to you or your circumstances, please write "not applicable" or "N/A."
• If you need more space to respond to a question, please find additional space on the last page.
• For the purposes of these questions, "immediate family member," means your spouse, children, and other family
members as defined in these instructions. This includes adult children. It also includes any relatives, by whether by
blood or marriage, who resides in your household or to whom you provide financial support.
• If your family member is retired, please write down the occupation and position/rank he or she last held.
1. Please provide the following information about yourself or any immediate family members, who are a current or
former member of the Union Solidarity and Development Association (USDA).
Name

Relationship

Date of Birth
(mm-dd-yyyy)

Position or Rank

a.
b.
c.

2. Please provide the following information about yourself or any immediate family members, who are a current or
former member of the State Peace and Development Council (SPDC).
Name

Relationship

Date of Birth
(mm-dd-yyyy)

Position or Rank

a.
b.
c.

3. Please provide the following information about yourself or any immediate family members, who are a current or
former member of the State Law and Order Restoration Council (SLORC).
Name

Relationship

Date of Birth
(mm-dd-yyyy)

Position or Rank

a.
b.
c.

4. Please provide the following information about yourself or any immediate family members, who are a current or
former employee in any Burmese state-owned enterprise (SOE), in the Burmese civil service, or in the Burmese military.
Name

Relationship

Date of Birth
(mm-dd-yyyy)

Position or Rank

a.
b.
c.
DS-5537
01-2018

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I understand all the information I have provided in, or in support of, this application may be provided to other U.S.
government agencies authorized to use such information for purposes including enforcement of the laws of the United
States. I understand all of the information contained in this form and I certify under penalty of perjury under the laws of
the United States of America that the foregoing is complete, true, and correct. I understand that any willfully false or
misleading statement or willful concealment of a material fact made by me herein may result in refusal of the visa, denial
of admission to the United States, and, may subject me to criminal prosecution and/or removal from the United States.
Signature
Name

Date (mm-dd-yyyy)

Continuation from Page 1 (if needed).
Please ensure you specify to what question(s) you are reponding. If further space is required, attach additional sheets.

PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average XX minutes per response, including
time required for searching existing data sources, gathering the necessary documentation, providing the information
and/or documents required, and reviewing the final collection. You do not have to supply this information unless this
collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to: [email protected].
CONFIDENTIALITY STATEMENT
AUTHORITIES: The information on this form is requested pursuant to Section 212(a) and 221 and as required by
Section 222 of the Immigration and Nationality Act. Section 222(f) provides that the records of the Department of State
and of diplomatic and consular offices of the United States pertaining to the issuance and refusal of visas or permits to
enter the United States shall be considered confidential and shall be used only for the formulation, amendment,
administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of
such records may, in the discretion of the Secretary of State, be made available to a court provided the court certifies
that the information contained in such records is needed in a case pending before the court.
PURPOSE: The U.S. Department of State uses the information provided on this form to determine an individual's
eligibility for a U.S. visa. Individuals who fail to submit this form or who do not provide all the requested information may
be denied a U.S. visa. Although furnishing this information is voluntary, failure to provide this information may delay or
prevent the processing of an individual visa application.
DS-5537

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