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Fillable Printable Form DS-4139

Fillable Printable Form DS-4139

Form DS-4139

Form DS-4139

U.S. Department of State
SIGNATURE CARD
Section 1 Applicant Information
1. Principal's PID2. Applicant's PID3. Mission Type4. Country
5. Surname6. Given Name7. Date of Birth (mm-dd-yyyy)
8. Nationality9. Sex10. Expected Date of Departure (mm-dd-yyyy)
For U.S. Government Use Only
(Shaded Area)
1. Card Type Issued
Section 2 Certifying Authority
WARNING
This information is provided to the U.S. Department of State in accordance with the requirements of United
States law (Title 18, U.S. Code, Section 1001) that all such statements are truthful. False information will be
considered a violation of U.S. law and, therefore, an abuse of the privileges and immunities to which an
individual's status may entitle him or her.
Certifier's Signature
Date
NameTitle
DS-4139
06-2015
Page 1 of 2
(mm-dd-yyyy)
A. Applicant signs below
USE BLACK INK ONLY
2. Card Expiration Date
(mm-dd-yyyy)
*OMB APPROVAL NO.1405-0105
EXPIRATION DATE: 03-31-2018
ESTIMATED BURDEN: 5 MIN.
Privacy Act Statement for the Foreign Diplomatic Services Application Database and Paperwork Reduction Act Statement
*The Privacy Act of 1974, as amended, 5 U.S.C. 552a contains provisions
regarding the maintenance, collection, use, and dissemination of information
about United States citizens and aliens lawfully admitted for permanent
residence in the United States. The following information is provided in
accordance with subsection (e) (3) of the Privacy Act.
AUTHORITIES: The information is sought pursuant to Vienna Convention on
Diplomatic Relations of 1961; Vienna Convention on Consular Relations of
1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations
Immunities Act (22 U.S.C. 288e (a)); Foreign Missions Act of 1982 (22 U.S.C.
4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to maintain a
record of all individuals actively working at foreign missions or international
organizations in the United States or its territories and who are entitled to a
range of diplomatic or consular benefits, privileges, and immunities. This
information is maintained by the Office of Foreign Missions at the U.S.
Department of State. The information is collected in order to (a) determine the
acceptability of a foreign person by the U.S. Department of State as a
diplomatic or consular officer of other international organization or foreign
government employee; (b) issue appropriate individuals an official identification
card; (c) register mission and personal vehicles and issue appropriate vehicle
registrations and license plates; (d) exempt certain individuals from sales taxes,
gasoline taxes, utility taxes, and drivers' license registration fees; and (f)
determine the eligibility of imported goods for exemption from duties otherwise
imposed by the Bureau of Customs and Border Protection. It is also used to
notify the State Department of the termination of diplomatic, consular, and
foreign employees.
Information on such individuals is submitted electronically directly into the
Foreign Diplomatic Services Application Database by accredited members of
the administrative staff at foreign missions or international organizations in the
United States, who have been given permission by the Office of Foreign
Missions to enter data into the database. Certain biographical and professional
information is collected from administrative staff in order for the State
Department to determine their eligibility to access and enter information into the
database.
ROUTINES USES: The principal users of this information are offices within the
U.S. Department of State, including but not limited to the Office of Protocol, the
Office of Foreign Missions, and the Office of Visa Services. In responses to
inquiries from law enforcement agencies, the Office of Protocol may confirm
status as recognized by the U.S. Department of State. Information may also be
provided to other government agencies having statutory or other lawful
authority to maintain such information. The information provided on this form
may be provided to other federal, state, and local government agencies for law
enforcement, administrative or other statutorily authorized purposes as covered
in STATE 36, Security Records. This information also may be provided to the
employing foreign government or international organization.
DISCLOSURE: Submission of information into this database is voluntary;
however, failure to provide any of the requested information may prevent
acceptance as a diplomatic or consular officer or other employee of a foreign
government of international organization, and the extension of benefits to
principals or family members as provided in the above-cited authorities. For
more information, please see the Systems of Record Notice and Privacy Impact
Assessment for the Office of Foreign Missions Information System at
Page 2 of 2DS-4139
PAPERWORK REDUCTION ACT: *Public reporting burden for this collection
of information is estimated to average 5 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: M/OFM, 3507
International Place NW, Washington, DC 20008.
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