Form DS-4285 PORT COURTESIES REQUEST

OMB APPROVAL NO. 1405-0105
EXPIRATION DATE: .xx-xx-xxxx
ESTIMATED BURDEN: 5 MINUTES*

U.S. Department of State

PORT COURTESIES REQUEST
GENERAL INFORMATION
Last Name

First Name

Title

Date of Birth (mm-dd-yyyy)

Visa Foil Number

Passport Number

Visa Type

For Chiefs of State and Heads of Governments, to confirm this visit, contact U.S. Secret Service (202) 406-7650 and fax (202) 406-7560.
For Foreign Ministers, to confirm this visit contact U.S. Security Protection, State Department Security Service (202) 895-3600 and fax (202) 895-3613.
Chief of State/Head of Government?

Requesting U.S. Secret Service?

If yes, Requesting Protection For?

Foreign Minister?

Requesting State Department Diplomatic Security?

Continue on to DC?

ARRIVAL FLIGHT INFORMATION
First Port of Entry into the United States

Arrival Date (mm-dd-yyyy)

Arrival Time (hh:mm)

Flight Type (Select one)

Flight Carrier Name (If Commercial)

Flight Number (If Commercial)

Aircraft Make (If Special-Private)

Aircraft Model (If Special-Private)

Tail Number (If Special-Private)

Call Sign (If Special-Private)

FBO

CONTINUING TO WASHINGTON, DC (Chief of State/Heads of Government or Foreign Ministers ONLY)
Washington DC Port of Entry

Arrival Date (mm-dd-yyyy)

Arrival Time (hh:mm)

Flight Type (Select one)

Flight Carrier Name (If Commercial)

Flight Number (If Commercial)

Aircraft Make (If Special-Private)

Aircraft Model (If Special-Private)

Tail Number (If Special-Private)

Call Sign (If Special-Private)

FBO

SECURITY AND PROTECTION
If you are requesting Diplomatic Security protection, please send a Diplomatic Note to DSPL@state.gov or send a fax 202-895-3613. Notification must
be submitted three business days in advance of the arrival date.
For Chiefs of State/Heads of Government: Are you requesting U.S. Government Security Protection from the U.S. Secret Service?
If yes, are you requesting protection for the duration of the visit OR Courtesies of Port only?
For Foreign Ministers - Will you request U.S. Government Security Protection from the State Department Diplomatic Security Service?

DS-4285
xx-2014

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GREETERS: Per U.S. Government regulations, there is a maximum of two (2) greeters allowed in the government inspection area for all arrivals.
Greeter 1 Name

Greeter 1 Title

Greeter 2 Name

Greeter 2 Title

ARMED SECURITY
If armed security personnel is accompanying the dignitary, U.S. Secret Service or Diplomatic Security must be notified three business days in advance
of the arrival date.
ARMED SECURITY 1
Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

Name

Rank

Service

Passport Number

Visa Type

Weapon (Make)

Weapon (Model)

Weapon (Serial Number)

Weapon (Caliber)

Weapon (No. rounds of
ammunition)

ARMED SECURITY 2

ARMED SECURITY 3

ARMED SECURITY 4

ARMED SECURITY 5

ARMED SECURITY 6

ARMED SECURITY 7

DS-4285

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PASSENGER MANIFEST
Please provide Name, Title, Date of Birth, Passport ID Number, and Visa Type for each of the accompanying members of the delegation to include the
dignitary and spouse, if accompanying. Please include the same information for the flight crew (private aircraft only).
ACCOMPANYING MEMBER 1
Name

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

Title

Date of Birth (mm-dd-yyyy) Passport ID Number

Visa Type

ACCOMPANYING MEMBER 2
Name

ACCOMPANYING MEMBER 3
Name

ACCOMPANYING MEMBER 4
Name

ACCOMPANYING MEMBER 5
Name

ACCOMPANYING MEMBER 6
Name

ACCOMPANYING MEMBER 7
Name

ACCOMPANYING MEMBER 8
Name

OVERFLIGHT CLEARANCE NOTIFICATION FOR PRIVATE AIRCRAFT
Please contact the U.S. Department of State, Office of International Security and Peacekeeping, for flight clearance into U.S. airspace and airports,
and for relocation requirements. Notification must be submitted three business days in advance of the arrival date.
DEPARTURE FLIGHT INFORMATION
Departure Port from the United States

Departure Date (mm-dd-yyyy)

Departure Time (hh:mm)

Flight Type (Select one)

Flight Carrier Name (If Commercial)

Flight Number (If Commercial)

Aircraft Make (If Special-Private)

Aircraft Model (If Special-Private)

Tail Number (If Special-Private)

DS-4285

Call Sign (If Special-Private)

FBO (If Special - Private)

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GENERAL INSTRUCTIONS
Please e-mail this form to Port Courtesies at portcourtesies@state.gov. Requests should be received no less than three business days prior to the
arrival date. If security is being requested or security is traveling with the dignitary, three business days advance notice is required for transmittal to the
U.S. Secret Service or Diplomatic Security.
Requests during the normal work (8:15 am - 5:00 pm) week must be received by 4:00 pm.
On Fridays, requests must be received by 3:00 pm. On weekends/holidays/after hours, emergency requests should be directed to the Protocol Duty
Officer through the Department of State Operations Center.

PAPERWORK REDUCTION ACT STATEMENT
*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 data, providing the information required, and reviewing the final collection. In accordance with 5 CFR 1320.5(b), persons are not required to
respond to the collection of this information unless this form displays a currently valid OMB control number. Send comments on the accuracy of this estimate of the burden
and recommendations for educing it to M/OFM, 3507 International Place NW, Washington, DC 20008.

PRIVACY ACT 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 information solicited on this form will be used by the U.S. Department of State (DOS) to adjudicate requests for the assignment of DOS representatives to
escort eligible senior officials of foreign governments and accompanying members through security screening processes.
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: Submission of information is voluntary; however, failure to provide any of the requested information may result in ineligibility for expedited port courtesy
clearance.

DS-4285

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