Request for Determination of Possible Loss of United States Citizenship

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.