Form DS-4079 Request for Determination of Possible Loss of United Sta

U. S. Department of State

OMB NO. 1405-0178
EXPIRES:
Estimated Burden - 15 minutes

BUREAU OF CONSULAR AFFAIRS

REQUEST FOR DETERMINATION OF POSSIBLE LOSS OF
UNITED STATES CITIZENSHIP
The following information is needed to determine your present citizenship status and possible loss of U.S.
citizenship. You cannot lose U.S. citizenship unless you VOLUNTARILY perform an act designated by U.S.
statute and do so with the intent to relinquish U.S. 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
1. Name (Last, First, MI)

2. Date of Birth

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

5.

3. Place of Birth

(b) Issued at (Place)

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

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

No;

Yes

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
Date (To) (mm-dd-yyyy)
Country

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

7. 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?)

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

8. Are you a national or citizen of any other country other than the United States?
(a) If yes, of what country?
(b) If yes, did you acquire that citizenship in the foreign country by:

DS-4079 (Formerly FS-581)
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(c) If other, explain.

(d) If you checked YES to question 8 (B) part (iii) by what means, or in what kind of proceeding, were you naturalized as a citizen of a
foreign state?

9. Have you taken an oath or made an affirmation or other formal declaration of allegiance to a foreign state?

Yes

No

If yes, please provide a date (mm-dd-yyyy) and country
(a) If you checked YES to question 8 or 9 or both, 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.

10. Have you served in the armed forces of a foreign state?

Yes

No

Yes

No

Yes

No

(a) If so, what country?
(b) In which branch of the armed forces did you serve?
(c) Dates of Service (mm-dd-yyyy)
(d) What ranks did you hold?
(e) What was your highest rank?

(f) What responsibilities did you have and what functions and activities were you engaged in?

(g) Did you take an oath? If so, describe the oath.

11. Have you accepted, served in, or performed the duties of any office, post or employment with the government of a
foreign state?
(a) If yes, please provide dates of service, country and the job title

(b) What were your duties and responsiblities for each of the foreign government jobs you held?

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Yes

No

(a) Did you maintain a residence? If yes, please explain.

Yes

No

(b) Did you own property? If yes, please explain.

Yes

No

(c) Do you have family or social ties? If yes, please explain.

Yes

No

(d) Do you vote? If yes, please explain.

Yes

No

(a) Do you maintain a residence? If yes, please explain.

Yes

No

(b) Do you own property? If yes, please explain.

Yes

No

(c) Do you have family or social ties? If yes, please explain.

Yes

No

(d) Do you vote? If yes, please explain.

Yes

No

(e) Do you file U.S. income or other tax returns? If yes, please explain.

Yes

No

(c) Did you take an oath, affirmation, declaration or allegiance in connection with the job? If yes, describe the oath,
affirmation, declaration or allegiance.

12. What ties did you have to the country where you performed the act or acts indicated in Questions 8-11? For example:

(e) What other ties did you have to the country where you performed the act or acts indicated in Questions 8-11?

13. What ties do you retain with the United States? For example:

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(f) Do you maintain a profession, occupation, or license in the United States? If yes, please explain.

Yes

No

(g) Have you registered your children as citizens of the United States?

Yes

No

Yes

No

Yes

No

Yes

No

14. What passport do you use to travel to and from the United States?

15. What passport do you use to travel to and from other countries?

16. Have you renounced your U.S. nationality at a U.S. Consulate or Embassy? If yes, provide a date and place.

17. Describe in detail the circumstances under which you performed the act or acts indicated in Questions 8-16.

18. Did you perform the act or acts voluntarily?
(a) If not, in what sense was your performance of the act or acts involuntary?

(b) Did you perform the acts with the intent to relinquish U.S. citizenship? If so, please explain your answer.

19. Did you know that by performing the act described in Questions 8-18 you might lose U.S. citizenship? Please explain your answer.

20. Your answers on this form will become part of the official record in your case. Before signing this form, you are advised to consider
consulting 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.
If your answer to each of the questions above is "No," please sign below before a Consular Officer at a U.S. Embassy or Consulate. If you
answered "Yes", to one or more of questions 8-19 and your intent was completely VOLUNTARY, please continue with PART II.

Subscribed and Sworn

[SEAL]

Signature

Signature of Consular Officer
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21. 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 above with the intent of
relinquishing United States citizenship. If you voluntarily performed an act stated
above with the intent to relinquish United States citizenship, you may sign Part II of
this statement before a Consular Officer at a U.S. Embassy or Consulate. The U.S.
Consulate or Embassy will prepare the forms necessary to document your loss of
U.S. citizenship.
PART II
STATEMENT OF VOLUNTARY RELINQUISHMENT OF U.S. CITIZENSHIP
Subscribed and Sworn
, performed the act of expatriation indicated in Questions 8-19,

I,
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]

PRIVACY ACT STATEMENT
AUTHORITIES: 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.
PURPOSE: 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 other federal entities with law
enforcement responsibilities relating to or affected by nationality, including but not limited
to the U.S. Citizenship and Immigration Service, the Internal Revenue Service, and the
Federal Bureau of Investigation. 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.

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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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