<FirstName> <LastName>
<Address>
<Phone>
<email>

<date>

U.S. Department of State
Diversity Visa Program
P.O. Box 979079
St. Louis, Missouri 63197-9000

Re: Adjustment of Status Fee Payment for <FirstName> <LastName>

Dear Sir/Madam,
Enclosed please find the payment for Adjustment of Status fee for:

  DV Program Case Number:
  Selectee Surname:
  Selectee Given Name:
  Address:
  City: State: Zip Code:
  Payment for n persons adjusting status in the U.S.
  Total Amount enclosed: $<n * 330>

Thank you for your consideration.
Yours truly
<FirstName> <LastName>

Enclosures:
1. A USPS money order
2. A self-addressed stamped envelope