DS-4079 Questionnaire: Information for Determining Possible Loss

U. S. Department of State

OMB NO. 1405-XXXX
EXPIRES:
Estimated Burden - 15 minutes

BUREAU OF CONSULAR AFFAIRS

QUESTIONNAIRE
INFORMATION FOR DETERMINING POSSIBLE LOSS OF U.S. CITIZENSHIP
The following information is needed to determine your present citizenship status and possible loss of
citizenship. Your U.S. citizenship can not be lost without an intent on your part to relinquish voluntarily your
citizenship. You are advised to consult an attorney before completing this form. If you have any questions
about the form, you should discuss them with a member of our consular staff before completing the form.
You are requested to complete this form carefully. Use extra paper as needed and attach any supporting
documents to this form.

PART I
2. Date of Birth

1. Name (Last, First, MI)

4. (a) Last U.S. Passport Number

3. Place of Birth

(b) Issued at (Place)

(c) Issued on (Date)
(mm-dd-yyyy)

5. If not born in the United States, did you acquire citizenship by birth outside the United States to U. S. citizen parent(s):

Yes

No;

or Naturalization, naturalization petitions prior to 11/29/1990 were submitted to and adjudicated by a court. After that date they were
submitted to and adjudicated by INS/USCIS.

Yes

No
(b) Date of Naturalization (mm-dd-yyyy)

(a) Name of Naturalizing Court/Office

Date (From) (mm-dd-yyyy)

Dates and Countries of Residence Outside the United States Since Birth
Country
Date (To) (mm-dd-yyyy)

6. Have you:
(a) been naturalized as a citizen of a foreign state? If yes, please provide a date (mm-dd-yyyy) and country

Yes

No

(b) taken an oath or made an affirmation or other formal declaration of allegiance to a foreign state:

Yes

No

Yes

No

Yes

No

Yes

No

If yes, please provide a date (mm-dd-yyyy) and country
(c) served in the armed forces of a foreign state?
(1) If so, what country?
(2) Dates of Service (mm-dd-yyyy)
(3) What was your highest rank?
(d) accepted, served in, or performed the duties of any office, post or employment with the government of a foreign state?
If yes, please provide dates of service and country with each post

(e) renounced U.S. nationality at a U.S. Consulate or Embassy? If yes, provide a date and place

DS-4079 (Formerly FS-581)
11-2006

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7. If your answer to each of the questions asked in item 6 above is "No," please sign below before a Consular Officer at the U.S. Embassy or
Consulate or a notary public. If you answered "Yes", to one or more of the questions asked in Item 6 above, please continue with PART II or III.

Subscribed and Sworn
Signature

[SEAL]

Date (mm-dd-yyyy)

Signature of Notary Public

Date (mm-dd-yyyy)

8. You should be aware that under United States law, a citizen, may lose U.S. citizenship if
he/she voluntarily performs any of the acts specified in Part I, Item 6 with the intent of
relinquishing United States citizenship. If you voluntarily performed an act listed in
Part I, Item 6 with the intent to relinquish United States citizenship, you may sign Part II
of this statement before a Consular Officer at the U.S. Embassy or Consulate or a
notary public. The U.S. Consulate or Embassy will prepare the forms necessary to
document your loss of U.S. citizenship. If you believe loss of citizenship has not
occurred, either because the act you performed was not voluntary or because you did
not intend to relinquish U.S. citizenship, you should skip Part II, and complete Part III of
this form.
PART II
STATEMENT OF VOLUNTARY RELINQUISHMENT OF U.S. CITIZENSHIP
Subscribed and Sworn
, performed the act of expatriation indicated in Part I, Item 6,

I,

(a, b, c, d, or e) voluntarily and with the intent to relinquish my U.S. citizenship.

Signature

Date (mm-dd-yyyy)

Signature of Consular Officer

Date (mm-dd-yyyy)

[SEAL]

PART III
1. Please check "Yes" or "No":
(a) Are you a national or citizen of any other country other than the United States?

Yes

No

(i) Birth?

Yes

No

(ii) Marriage?

Yes

No

(iii) Naturalization or registration; if yes, please provide a date (mm-dd-yyyy)

Yes

No

(b) If yes, of what country?
(c) If yes, did you acquire that citizenship in the foreign country by:

(d) If other, explain.

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2. When did you first become aware that you might be a United States citizen (Give Approximate Date)?

3. How did you find out that you are a citizen of the United States? (For example, did you always know you were a U.S. citizen?
If not, when did you learn about your citizenship? Did someone tell you that you are a U.S. citizen?)

4. Describe as specifically as you can the act or acts you performed as indicated in Part I, Item 6.
(a) If you checked YES to question 6A, by what means, or in what kind of proceeding, were you naturalized as a citizen of a foreign state?

(b) If you checked YES to question 6 A or B, what was the nature of the oath you took? What were the words used? If you have a copy of the
oath please attach it.

(c) If you checked YES to question 6C, in what foreign armed services did you serve? What years? What ranks did you hold? What was the
highest rank? What responsibilities did you have and what functions and activities were you engaged in? Did you take an oath? If so, describe
the oath.

(d) If you checked YES to question 6D, for what foreign government did you work? For more than one? What was your job title or titles? What
were your duties and responsibilities for each of the foreign government jobs you held? Did you take an oath, affirmation or declaration or
allegiance in connection with the job? If so describe the oath, affirmation or declaration.

5. Describe in detail the circumstances under which you performed the act or acts indicated in Part 1, Item 6.

Did you perform the act or acts voluntarily?

YES

NO

(a) If not, in what sense was your performance of the act or acts involuntary?

(b) What was your intent toward your U.S. citizenship in performing the act or acts?

Did you perform the acts with the intent to relinquish U.S. citizenship?

YES

NO

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6. Did you know that by performing the act described in Part I, Item 6 you might lose U.S. citizenship? Please explain your answer.

7. What ties did you have to the country where you performed the act indicated in Part I, Item 6? For example, at the time you performed the act, did
you maintain a residence, did you own property, did you have family or social ties, did you vote, etc.?

8. What ties do you retain with the United States? For example, do you maintain a residence, have property, family or social ties, vote, file U.S.
income or other tax returns? Do you maintain a profession, occupation or license in the United States? Have you registered your children as
citizens of the United States?

9. (a) What passport do you use to travel to and from the United States?

(b) What passport do you use to travel to and from other countries?

Your answers on this form will become part of the official record in your case. Before signing this form, you are advised to consult with an attorney,
and to read over your answers to make certain that they are as complete and accurate as possible. If you would like to provide additional information
you believe relevant to a determination of your citizenship status, and in particular to your intention or lack of intention to relinquish U.S. citizenship,
you may attach separate sheets with that information.
To complete the form, please sign below before a Consular Officer at the U.S. Embassy or Consulate or a notary public.

Subscribed and Sworn

[SEAL]

Signature

Date (mm-dd-yyyy)

Signature of Consular Officer

Date (mm-dd-yyyy)

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PRIVACY ACT STATEMENT
The information on this form is requested under the authority of 8 U.S.C. 1104, 1481, 1483,
1488, and 1501, and 22 U.S.C. 212. Although furnishing the information is voluntary,
applicants may not be eligible for a U.S. passport or for relinquishment or renunciation of
U.S. nationality if they do not provide the required information. The principal purpose of
gathering this information is to determine if the individual performed a potentially
expatriating act as defined in 8 U.S.C. 1481 voluntarily and with the intention of
relinquishing U.S. nationality.
ROUTINE USES The information solicited on this form may be made available to foreign
government agencies to fulfill passport control and immigration duties, to investigate or
prosecute violations of law, or when a request for information is made pursuant to
customary international practice. In the event a finding of loss of nationality is made, the
information solicited on this form may be made available to the following federal agencies:
U.S. Citizenship and Immigration Service (8 U.S.C. 1501); Internal Revenue Service (26
U.S.C. 6039G(e)(2)); Federal Bureau of Investigation (P.L. 103-159, 18 U.S.C. 922(d)(7), 18
U.S.C. 922(g)(7)). The information provided also may be released to federal, state or local
agencies for law enforcement, counter-terrorism and homeland security purposes; to
Congress and courts within their sphere of jurisdiction; and to other federal agencies for
certain personnel and records management matters.

PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 15 minutes
per response, including time required for searching existing data sources, gather 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: U.S. Department of State, A/ISS/DIR, 1800 G St. N.W., Washington, D.C. 20520.

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