1. Surname
I understand that I am authorized to use this account for the sole purpose of requesting certain privileges and benefits provided by the U.S.
Department of State to the mission(s) listed in Section 4 of this application. Any other users of this account are strictly prohibited. I will not
divulge my login or password to any other person. I will notify the OFM HelpDesk if I have any reason to believe my password has been
compromised. I further acknowledge that improper use could result in administrative action against me.
Print Name
Signature Date (mm-dd-yyyy)
U.S. Department of State
APPLICATION FOR OFM WEBSITE ACCOUNT
Email application to OFM HelpDesk at OFMeGovHelpDesk@state.gov
Type of Request
New Account Change to Existing Account Delete Account
Section 1 Applicant Information
Mission
Section 2 User Acknowledgement
DS-4140
07-2017
Page 1 of 2
*OMB APPROVAL NO.1405-0105
EXPIRATION DATE:05-31-2018
ESTIMATED BURDEN:10 MIN.
2. Given Name 3. Middle Initial 4. PID
5. Date of Birth (mm-dd-yyyy) 6. Telephone Number 7. E-mail Address
Section 3 Account Access (check applicable sections)
All Bonded Warehous Port Courtesies
Accreditation Customs Tax
Airport Escort DMV White House Tours
Privacy Act and Paperwork Reduction Statement
*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 purpose of this form is to authorize access to the Office of Foreign Missions' electronic data submission (e-Gov) system. The information solicited on
this form will be used to determine eligibility and create user accounts for the e-Gov system.
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other statutorily authorized
purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of access to the E-Gov system.
PAPERWORK REDUCTION ACT: *Public reporting burden for this collection of information is estimated to average 10 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.
click to sign
signature
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dd mmm yyyy
Section 6 Office of Foreign Missions Approval
Print Name
Signature
Date (mm-dd-yyyy)
Section 4 Authorized Missions
Mission City State ZIP Code
The applicant listed on this form is an accredited member of the post of which I am the head. I certify this applicant should have the account
access as indicated on this form. I acknowledge if I am made aware of or suspect any improper use of this account, I will promptly notify OFM
at OFMeGovHelpDesk@state.gov .
Print Name
Signature
Date (mm-dd-yyyy)
PID
Section 5 Head of Post Acknowledgement
E-mail
***Mission Seal Required***
DS-4140
Page 2 of 2
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signature
click to edit
dd mmm yyyy
click to sign
signature
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dd mmm yyyy
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