snsr019 Electronic Diversity Visa Lottery U.S. Department of State (hitp:www.state.gov) Bureau of Consular Affairs eDV AES: 12.6 @ Help (Help.aspx) Electronic Diversity Visa Entry Form (OMB Control Number: 1405-0163 Form: DS-5501 Expires: 08/31/2020 Estimated Burden: 30 minutes Ifyou need to go back and make a correction, do NOT use the back button on your browser. Instead use the appropriate button here or below: Go Back to Part1 || Go Back to Part 2 Part One - Entrant Information 1. Name a. Last/Family Name MUBARAK b. First Name ABDELGADIR . Middle Name OSMAN SABOUN 2. Gender Male 3. Birth Date March 15, 1989 4. City Where You Were Born ALGENANA, 5. Country Where You Were Born Sudan hitps:dvotory.state govlapplication aspx 18snsr019 6, Country of Eligibility for the DV Program Sudan 7. Passport In order to submit an entry for the Diversity Visa program, you must currently possess a valid, unexpired passport from your country of nationality, unless exempt (see below). Please answer A or B. A) Passport Information: Name On Passport: a, Last/Family Name MUBARAK b. First Name ABDELGADIR idle Name OSMAN SABOUN Passport Number: 05632624 Passport Expiration Date: March 19, 2024 Country/Authority of Issuance: Sudan 8. Entrant Photograph (Photograph received) 9. Malling Address a. In Care Of (optional) b, Address Line 1 ALGENANA htpssldvotory.state govlapplication aspx Electronic Diversity Visa Lottery 216snsr019 Electronic Diversity Visa Lottery c. Address Line 2 (optional) 4. City/Town ALGENANA «. District/County/Province/State ALREUAD/ALGENANAWEST DAR FUR Postal CodelZip Code 9. Country Sudan 10. Country Where You Live Today Sudan 11. Phone Number 0024991133578 12. E-mail Address saboon89@gmail.com (NOTE: This e-mail address will be used to provide you with adeitional information if you are selected.) 13. What is the highest level of education you have achieved, as of today? University Degree You must have a minimum of a high school diploma reflecting the completion of a full course of study (vocation schools or equivalency degrees are not acceptable) or be a skilled worker in an occupation that requires at least two years of training or experience to qualify (visit http://www.onetonline.org/ {http://www.onetontine.org/) to see if your occupation qualifies) for a Diversity Visa 14, What is your current marital status? Married and my spouse is NOT a U.S.citizen or U.S. Lawful Permanent Resident (LPR) htpssldvotory.state govlapplication aspx 36snsr019 Electronic Diversity Visa Lottery Legal separation is an arrangement when a couple remain married but live apart, following a court order. Ifyou and your spouse are legally separated, your spouse will not be able to immigrate with you through the Diversity Visa program. You will not be penalized if you choose to enter the name of a spouse from whom you are legally separated. If you are not legally separated by a court order, you must include your spouse even if you plan to be divorced before you apply for the Diversity Visa. Failure to list your eligible spouse is grounds for disqualification. If your spouse is a U.S. citizen or Lawful Permanent Resident, do not list him/her in your entry. 15. 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. Part Two - Derivatives 14. Spouse Name a. Last/Family Name OMER b. First Name FATIMA . Middle Name DAWUD 14d, Birth Date January 01, 1993 140, Gender Female 14f. City Where Spouse Was Born hitps:dvotory.state govlapplication aspx 406snsr019 ELGENEINA 14g. Country Where Spouse Was Born Sudan 14h. Spouse Photograph (Photograph received) 15. Child #1 Name a. LasFamily Name OSMAN SABOUN b. First Name YOUSIF . Middle Name ABDELGADIR 15d. Birth Date January 01, 2011 15e. Gender Male 15f. City Where Child Was Born ALGENANA, 15g. Country Where Child Was Born Sudan hitpssdvotory.sate govlapplication aspx Electronic Diversity Visa Lottery 56snsr019 Electronic Diversity Visa Lottery 15h, Child Photograph (Photograph received) Go Back to Part 1 || Go Back to Part 2 Please print this page for your personal records. You will need to use your browser's print button for this. PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average 30 minutes per response, including ime required for searching existing data sources, gathering the necessary documentation, providing the information andor documents required, and reviewing the final collection. You de 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: PRA_BurdenComments@state.gov. CONFIDENTIALITY STATEMENT: The information asked for on this form is requested pursuant to Section 222 of the Immigration and Nationality Act. INA Section 222(° provides that visa issuance and refusal records shall be considered confidential and shall be used only forthe formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies of visa records may be made available to a court which certifies that the information contained in such records is needed in a case pending before the cour. PRIVACY POLICY: For information on the Department of State's privacy policy, regarding the nature, purpose, use, and sharing of any Personally Identifiable Information (Pll) collected via this website please click here (htps:/iwww.state.goviprivacy-policy). TSA.c0¥ _(nttp:siwww.usa.gov) @ travel state.gov (hitpsitravel state.gov) f Welcome Page (/defaull aspx) Top of page This site fs managed by the Bureau of Consular Affairs, U.S. Department of State. Extemal links to other Internet sites should not be construed as an endorsement ofthe views contained therein, hitpssdvotory.sate govlapplication aspx 66