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Department of State Seal
U.S. Department of State
Bureau of Consular Affairs
eDV AES: 12.11
Electronic Diversity Visa Entry Form
OMB Control Number: 1405-0153
Form: DS-5501
Expires: 08/31/2025
Estimated Burden: 30 minutes
If you 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:
Part One – Entrant Information
1. Name
a. Last/Family Name
Abdi
b. First Name
Abdihakim
c. Middle Name
Osman
2. Gender
Male
3. Birth Date
September 24, 2005
4. City Where You Were Born
Galkaio
5. Country Where You Were Born
Somalia
6. Country of Eligibility for the DV Program
Somalia
7. Entrant Photograph
(Photograph received)
8. Mailing Address
a. In Care Of (optional)
b. Address Line 1
Dhagacade
c. Address Line 2 (optional)
Street
d. City/Town
Galkaio
e. District/County/Province/State
Galkaio, mudug, puntland state
f. Postal Code/Zip Code
NA
g. Country
Somalia
9. Country Where You Live Today
Somalia
10. Phone Number
+252906939330
11. E-mail Address
Updyhakiimothman@[Link]
(NOTE: This e-mail address will be used to provide you with additional information if you
are selected.)
12. What is the highest level of education you have achieved, as of today?
High School, no 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 [Link] to see if your occupation qualifies) for a
Diversity Visa.
13. What is your current marital status?
Unmarried
Legal separation is an arrangement when a couple remain married but live apart,
following a court order. If you 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.
14. 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.
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 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:
PRA_BurdenComments@[Link].
CONFIDENTIALITY STATEMENT: The information asked for on this form is requested
pursuant to Section 222 of the Immigration and Nationality Act. INA Section 222(f)
provides that visa issuance and refusal records 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 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 court.
PRIVACY POLICY: For information on the Department of State’s privacy policy, regarding
the nature, purpose, use, and sharing of any Personally Identifiable Information (PII)
collected via this website please click here.
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