Information Collection

Request for Determination of Possible Loss of United States Citizenship

IC 181472 under ICR 202002-1405-003 · OMB 1405-0178.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0178 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-4079 Request for Determination of Possible Loss of United States Citizenship	Form and Instruction
DS-4079 Request for Determination of Possible Loss of United Sta DS-4079 Revised.pdf	Form and Instruction

IC Title:

Request for Determination of Possible Loss of United States Citizenship

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR 50.40 22 CFR 50.50

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-4079	Request for Determination of Possible Loss of United States Citizenship	DS-4079 Revised.pdf		Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,250

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,250	2,650	600
Annual IC Time Burden (Hours)	5,688	5,288	400
Annual IC Cost Burden (Dollars)	63,521	63,521	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.