Request for Determination of Possible Loss of United States Citizenship

Forms and Documents

Document Name	Status
Form DS-4079 Request for Determination of Possible Loss of United States Citizenship Form and Instruction	Modified
Legal Authorities (10-2013).doc Supplementary Document	2013-10-24
1405-0178 Supporting Statement v2 (1-30-14).doc Supporting Statement A	2014-01-30

IC Document Collections

IC ID	Document Title	Status
181472	Request for Determination of Possible Loss of United States Citizenship Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0178	ICR Reference No: 201310-1405-003
Status: Historical Active	Previous ICR Reference No: 201010-1405-001
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Request for Determination of Possible Loss of United States Citizenship
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/30/2014
	Date Received in OIRA: 10/24/2013
Terms of Clearance: In its next submission, State Department will report on efforts to provide an electronic filing option.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	36 Months From Approved	01/31/2014
Responses	1,729	0	1,132
Time Burden (Hours)	432	0	283
Cost Burden (Dollars)	32,532	0	0

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Abstract: The purpose of the DS-4079 questionnaire is to determine current citizenship status and the possibility of loss of United States citizenship. The information provided in the questionnaire assists consular officers and the Department of State in determining if the U.S. citizen has lost his or her nationality by voluntarily performing an expatriating act.

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Authorizing Statute(s): US Code: 8 USC 1481(a) Name of Law: Immigration and Nationality Act (INA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 39823	07/02/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 63560	10/24/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Determination of Possible Loss of United States Citizenship	DS-4079	Request for Determination of Possible Loss of United States Citizenship

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,729	1,132	0	0	597	0
Annual Time Burden (Hours)	432	283	0	0	149	0
Annual Cost Burden (Dollars)	32,532	0	0	0	32,532	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden hours have increased because of an increase in number of respondents. Burden costs have increased due to calculation for mileage travel costs and Express mail costs for document submission.

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Annual Cost to Federal Government: $125,356

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 10/24/2013

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