DV LOTTERY 2025

 

Electronic Diversity Visa Entry Form

OMB Control Number: 1405-0153
Form: DS-5501
Expires: 08/31/2025
Estimated Burden: 30 minutes

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Part One - Entrant Information

1. Name

a. Last/Family Name
    AMMARCHA
b. First Name
    SAMIR
c. Middle Name
    

2. Gender

Male

3. Birth Date

July 10, 1979

4. City Where You Were Born

KHEMIS MILIANA

5. Country Where You Were Born

Algeria

6. Country of Eligibility for the DV Program

Algeria

7. Entrant Photograph

(Photograph received)

8. Mailing Address

a. In Care Of (optional)

    Samir Ammarcha

b. Address Line 1

    Villa EPLF N 8

c. Address Line 2 (optional)

    

d. City/Town

    KHEMIS MILIANA

e. District/County/Province/State

    AIN DEFLA

f. Postal Code/Zip Code

    44225

g. Country

    Algeria

9. Country Where You Live Today

Algeria

10. Phone Number

213 792352606

11. E-mail Address

samir.ammarcha@gmail.com

(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?

Master's 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/ 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

0

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.