Form DS-4079 Questionnaire - Loss of United States Nationality; Attes

U. S. Department of State

BUREAU OF CONSULAR AFFAIRS

QUESTIONNAIRE - LOSS OF
UNITED STATES NATIONALITY; ATTESTATIONS
NOTICE: You must complete this form, Questionnaire - Loss of United States Nationality (Questionnaire) if you are
requesting a Certificate of Loss of Nationality of the United States (CLN) under Immigration and Nationality Act (INA)
section 349(a)(1) - (5). The U.S. Department of State (the Department) will consider the responses you provide on this
Questionnaire and other evidence to determine whether to approve or deny your request for a CLN. The Department
cannot approve your request for a CLN unless, in addition to performing one of the acts listed below, you have met all
other legal requirements. The information you provide on this Questionnaire also may be used for other purposes as
specified in 22 CFR Part 50 and the Privacy Act Statement contained on this form.
If you need translation assistance and/or have any questions, please contact the U.S. embassy or consulate
where you plan to submit your request for a CLN.
STEP 1: Please read the instructions carefully before completing and submitting this form, DS-4079 Questionnaire Loss of United States Nationality (Questionnaire).
STEP 2: Complete, but do not sign, the Questionnaire. You may attach additional pages if you need more space for
any response(s).
STEP 3: Submit the completed (but unsigned) Questionnaire and any supporting documents according to
instructions provided by the U.S. embassy or consulate to which you will submit your request for a CLN. The U.S.
embassy or consulate will confirm receipt and provide further instructions, including how to schedule your initial
interview appointment(s).
STEP 4: Complete your initial interview, which may be conducted in person, by telephone, or by email exchange (if
available) at the U.S. embassy or consulate you have selected.
NOTE: You may be asked to submit additional information before and/or during your initial interview.
STEP 5: Schedule a subsequent in-person interview appointment before a U.S. diplomatic or consular officer
abroad. Bring the completed (but unsigned) hard copy Questionnaire and other required documents with you to your
in-person interview appointment.
NOTE: You may be asked to submit additional information before and/or during your in-person interview
appointment.
STEP 6: Attend your in-person interview. At the end of this interview, the U.S. consular or diplomatic officer will ask
you to sign the completed Questionnaire under oath or affirmation in their presence.
NOTE: You may be asked to submit additional information and/or to return for another in-person interview.
STEP 7: Once all interviews are complete and you have provided any additional requested information, the U.S.
diplomatic or consular officer will forward to the Department the signed Questionnaire, supporting documentation,
and their recommendation regarding your request for a CLN.
NOTE: You may be asked to submit additional information and/or to return for another in-person interview.
STEP 8: After review, the Department will send its decision approving or denying your request for a CLN to the U.S.
embassy or consulate for delivery to you and/or your authorized representative.
REQUIRED DOCUMENTS
NOTE: You must bring ORIGINAL documents or copies certified by the custodian of the record and bearing the seal of
the issuing vital records office, court, or other authority. The U.S. embassy/consulate cannot accept photocopies or
notarized copies of documents.
To properly complete a request for a CLN, you must provide the following:
1. Evidence of your U.S. nationality. You may submit a U.S. passport, U.S. passport card, Consular Report of Birth
Abroad, Certificate of Naturalization, Certificate of Citizenship, or U.S. birth certificate. If you do not have any of these
documents, contact the U.S. embassy or consulate nearest to you for information on other acceptable evidence.
2. Proof of identity. You must present a full validity, unexpired U.S. or foreign passport or other government-issued
photo identification (ID) as proof of identity.
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3. Evidence of current legal name. You must present a court order, marriage certificate, divorce decree, or other
evidence establishing a legal change of name.
4. Evidence of other nationalities, if any. If requested, you must submit a valid passport and/or Certificate of
Naturalization (or other comparable document) issued by the government of the foreign state.
5. Additional documents. You may be asked to provide additional documents.
HOW TO COMPLETE THIS FORM
OATH OF RENUNCIATION. If you are requesting a CLN based on taking an oath of renunciation of U.S. nationality
under Immigration and Nationality Act (INA) section 349(a)(5), complete PART I-A; PART I-B and PART II of this form.
Part II must be completed in person before a U.S. diplomatic or consular officer abroad. You are not required to
complete any other part of this form. NOTE: DO NOT complete this form if you are requesting a CLN based on
taking the oath of renunciation while in the United States under INA 349(a)(6). Contact the Department of Homeland
Security for information about taking the oath of renunciation while in the United States.
OTHER ACTS. If you are requesting a CLN based on an act you performed in the past as described in Immigration and
Nationality Act (INA) section 349(a)(1)-(4) and listed below, complete the parts of this Questionnaire indicated below for
that act. You may (but are not required to) complete the parts indicated for the other acts.
1. NATURALIZATION IN A FOREIGN STATE. If you naturalized in a foreign state after the age of 18 and are claiming
loss of U.S. nationality based on that act, complete PART I-A, PART I-C, and PART II-A, -B, and -D of this form.
PART II must be completed in person before a U.S. diplomatic or consular officer abroad. You are not required to
complete any other part of this form.
2. OATH OF ALLEGIANCE TO A FOREIGN STATE. If you took an oath of allegiance to a foreign state after the age of
18 and are claiming loss of U.S. nationality based on that act, complete PART I-A, PART I-D and PART II-A, -B, and
-D of this form. Part II must be completed in person before a U.S. diplomatic or consular officer abroad. You are not
required to complete any other part of this form. NOTE: You may be asked to submit a copy of the oath.
3. SERVICE IN ARMED FORCES OF A FOREIGN STATE. If you served in the armed forces of a foreign state and are
claiming loss of U.S. nationality based on that act, complete PART I-A, PART I-E and PART II-A, -B, and -D of this
form. PART II must be completed in person before a U.S. diplomatic or consular officer abroad. You are not
required to complete any other part of this form. NOTE: You may be asked to submit a copy of your military
orders.
4. EMPLOYMENT IN THE GOVERNMENT OF A FOREIGN STATE. If you accepted employment with, or are serving
in a position in, the government of a foreign state and are claiming loss of U.S. nationality based on that act,
complete PART I-A, PART I-F and PART II-A, -B, and -D of this form. PART II must be completed in person
before a U.S. diplomatic or consular officer abroad. You are not required to complete any other part of this form.
NOTE: If you took an oath in connection with your employment, you may be asked to submit a copy of the oath.
INSTRUCTIONS FOR PART I-A BACKGROUND INFORMATION
You must complete PART I-A, items 1-8, if you are requesting a Certificate of Loss of Nationality of the United States
(CLN) under Immigration and Nationality Act (INA) section 349(a)(1)-(5). If you need more space, please attach
additional page(s) and list the item number to which you are responding and your response(s) on the page(s).
Note: DO NOT complete this form if you are requesting a CLN based on taking an oath of renunciation within the
United States under INA 349(a)(6). Contact the Department of Homeland Security for information about taking an oath
of renunciation while in the United States.
1. Name(s)/Aliases: Provide your full legal name and any aliases.
2. Mailing Address, Email Address, and Phone Number. Provide your current physical mailing address (do not list a
P.O. box, but you may list an A.P.O. address and/or other foreign address) email address, and phone number.
3. Date of Birth. Write the month before the date and year. (Example: 10-02-1990 - month-day-year)
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3. Date of Birth. Write the month before the date and year. (Example: 10-02-1990 - month-day-year)
4. Place of Birth. List city, state/province, and country.
5. How did you acquire U.S. nationality? If you acquired U.S. nationality at birth, indicate if you acquired by birth in
the United States or by birth abroad to a U.S. citizen parent(s). If you acquired U.S. nationality by naturalization:
(a) List the name, city, and state of the U.S. court or the field office of U.S. Citizenship and Immigration Services
(formerly Immigration and Naturalization Service) that issued your Certificate of Naturalization or Certificate of
Citizenship.
(b) Enter the date of naturalization. Write the month before the date and year. (Example: 10-22-2010 month-day-year.)
6. Documentation of U.S. Nationality. Check all that apply.
If you have been issued a U.S. passport:
(a) Enter the number of your most recent U.S. passport; if unknown, indicate "Unknown."
(b) Enter the place where your most recent U.S. passport was issued; if unknown, enter "Unknown."
(c) Enter the date that your most recent U.S. passport was issued. Write the month before the date and year.
(Example: 10-22-2010 - month-day-year). If unknown, enter "Unknown."
7. Ties to the United States. Respond to items 7(a)-(b). Attach additional pages if needed.
8. Other Nationalities. Check "Yes" or "No" if you are a national or citizen of any country other than the United States.
If "Yes," please list each country and provide the requested information. Attach additional pages if necessary. NOTE:
If you are requesting a CLN based on naturalization in a foreign country you must also complete PART I-C.
INSTRUCTIONS FOR PART I-B OATH OF RENUNCIATION
You must complete PART I-B, items 9-12 (and PART I-A and PART II) if your request for a Certificate of Loss of
Nationality of the United States (CLN) is based on taking an oath of renunciation of the United States before a U.S.
diplomatic or consular officer in a foreign country.
NOTE: DO NOT complete this form if you are requesting a CLN based on taking an oath of renunciation within the
United States under Immigration and Nationality Act section 349(a)(6). Contact the Department of Homeland Security
for information about taking an oath of renunciation while in the United States.
9. Request. If you are requesting a CLN based on taking an oath of renunciation of U.S. nationality before a diplomatic
or consular officer of the United States in a foreign country, please respond to items 9-12. If you are requesting a
CLN based on another act, you are not required to complete this section, PART I-B.
10. Appointment Location. If you are requesting a CLN based on taking an oath of renunciation of U.S. nationality
before a U.S. diplomatic or consular officer in a foreign country, please indicate the U.S. embassy or consulate where
you plan to have your in-person interview and take the oath. [U.S. Embassy X, country; or U.S. Consulate/Consulate
General X, country]
11. Voluntariness. Respond to items 11(a)-(c).
12. Intent. State your intent with respect to your U.S. nationality.
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HOW TO COMPLETE THIS FORM - Continued
INSTRUCTIONS FOR PART I-C NATURALIZATION IN A FOREIGN STATE
You must complete PART I-C, items 13-16 (and PART I-A and PART II-A, -B, -D) if your request for a Certificate of
Loss of Nationality of the United States (CLN) is based on naturalizing in a foreign country.
13. Request. If you are requesting a CLN based on naturalizing in a foreign country, please respond to items 13-16. If
you are requesting a CLN based on another act, you are not required to complete this section, PART I-C.
14. Details. For the foreign country in which you have naturalized, respond to items 14(a)-(e). Enter "Yes," "No," or "n/a"
(not applicable).
15. Voluntariness. Respond to items 15(a)-(c), and explain your answers.
16. Intent. Respond to item 16 and explain your answer.
INSTRUCTIONS FOR PART I-D OATH OF ALLEGIANCE TO A FOREIGN STATE
You must complete PART I-D, items 17-20 (and PART I-A and PART II-A, -B, -D) if your request for a Certificate of
Loss of Nationality of the United States (CLN) is based on taking an oath of allegiance to a foreign state.
17. Request. If you are requesting a CLN based on taking an oath of allegiance to a foreign state, please complete this
section, items 17-20. If not, you are not required to complete this section, PART I-D.
18. Details. Respond to items 18(a)-(e).
19. Voluntariness. Respond to items 19(a)-(c) and explain your answers.
20. Intent. Respond to item 20, and explain your answer.
INSTRUCTIONS FOR PART I-E SERVICE IN THE ARMED FORCES OF A FOREIGN STATE
You must complete PART I-E, items 21 - 24 (and PART I-A and PART II-A, -B, -D) if your request for a Certificate of
Loss of Nationality of the United States (CLN) is based on service in the armed forces of a foreign state. NOTE: You
may be asked to submit a copy of your military orders (entry, service, discharge orders).
21. Request. If you are requesting a CLN based on service in the armed forces of a foreign state, please respond to
items 21-24. If not, you are not required to complete this section, PART I-E.
22. Details of Service. Respond to items 22(a)-(f). Attach additional pages if necessary.
23. Voluntariness. Respond to items 23(a)-(c), and explain your answers.
24. Intent. Respond to item 24, and explain your answer.
INSTRUCTIONS FOR PART I-F EMPLOYMENT IN THE GOVERNMENT OF A FOREIGN STATE
You must complete PART I-F, items 25-28 (and PART I-A and PART II-A, -B, -D) if your request for a Certificate of
Loss of Nationality of the United States is based on accepting, serving in, or performing the duties of any office,
post or employment with the government of a foreign state.
25. Request. If you are requesting a CLN based on employment with the government of a foreign state, please respond
to items 25-28. If not, you are not required to complete this section, PART I-F.
26. Details of Employment. Respond to items 26(a)-(i). Use more pages if necessary.
27. Voluntariness. Respond to items 27(a)-(c) and explain your answers.
28. Intent. Respond to item 28, and explain your answer.
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HOW TO COMPLETE THIS FORM - Continued
INSTRUCTIONS FOR PART II ATTESTATIONS UNDER OATH OR BY AFFIRMATION
DO NOT COMPLETE PART II OR SIGN THIS FORM UNTIL YOU ARE IN PERSON BEFORE A U.S. DIPLOMATIC
OR CONSULAR OFFICER IN A FOREIGN COUNTRY.
Oath of Renunciation. You must complete all of PART II in-person before a U.S. diplomatic or consular officer in a
foreign country if you are requesting a Certificate of Loss of Nationality of the United States (CLN) based on taking the
oath of renunciation before a U.S. diplomatic or consular officer in a foreign country under Immigration and Nationality
Act section 349(a)(5) and listed on Instruction page 2 of 5 of this form.
Other Acts. You must complete PART II-A, -B, and -D in-person before a U.S. diplomatic or consular officer in a foreign
country if you are requesting a Certificate of Loss of Nationality of the United States (CLN) based on performance of an
act specified in Immigration and Nationality Act section 349(a)(1)-(4) and listed on Instruction page 2 of 5 of this form.
NOTE: Your responses on this form will become part of the official record in your case. You may wish to consult an
attorney before signing this form in person before a U.S. diplomatic or consular officer. Please make sure your
responses are as complete and accurate as possible. If you would like to provide additional information you believe may
be relevant to your request for a Certificate of Loss of Nationality of the United States, please attach more pages with
that information.
DO NOT COMPLETE PART II OR SIGN THIS FORM UNTIL YOU ARE IN PERSON BEFORE A U.S. DIPLOMATIC
OR CONSULAR OFFICER IN A FOREIGN COUNTRY.
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U. S. Department of State

OMB NO. 1405-0178
EXPIRES: XX/XX/20XX
Estimated Burden - 43 minutes

BUREAU OF CONSULAR AFFAIRS

QUESTIONNAIRE - LOSS OF
UNITED STATES NATIONALITY; ATTESTATIONS
NOTE: PLEASE READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM.
PART I-A - BACKGROUND INFORMATION
1. Name(s)/Aliases (Last, First, MI)

2. Mailing Address, Email Address, and Phone Number.

3. Date of Birth (mm-dd-yyyy)

4. Place of Birth. (city, state/province, and country)

5. How did you acquire U.S. nationality?
I acquired U.S. nationality at birth
(If you acquired at birth, indicate if you acquired by birth in the United States or by birth abroad
and proceed to item 6.)
By birth in the United States
By birth abroad to a U.S. citizen parent(s)
I acquired U.S. nationality at some point after birth (naturalization)
(If you acquired U.S. nationality by naturalization, complete 5(a) and 5(b) below.)
5(a) City, state and name of court or U.S. immigration field office that issued your
Certificate of Naturalization or Certificate of Citizenship, if applicable

5(b) Date of Naturalization
(mm-dd-yyyy)

6. Documentation of U.S. Nationality (Check all that apply)

U.S. Passport
6(a) Last U.S. Passport Number:
6(b) Issued at (Place):
6(c) Issued on (Date)(mm-dd-yyyy):
U.S. Birth Certificate
Consular Report of Birth Abroad
Certificate of Naturalization
Certificate of Citizenship
Other (please specify):
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7. Ties to the United States

7(a) Residence
7(a)(i) Do you reside in the United States?
If "Yes," list your address.
7(a)(ii) Have you ever resided in the United States?
If "Yes," provide the city, state, and dates of residence.
City/State

From (mm-yyyy)

7(a)(iii) Do you currently maintain a residence in the United States?
If "Yes," provide the address(es) and dates of stay, if any.

Yes

No

To (mm-yyyy)

No

Dates of Stay (mm-yyyy)
From

To

7(b) Rights/Benefits. Do you receive any benefit or service or exercise any right or privilege
that requires U.S. citizenship and/or proof of residence in the United States? If yes, list below.

Yes

No

Check Yes or No

U.S. passport (unexpired)

Yes

No

Medical/Professional License(s)

Yes

No

Voting in U.S. elections

Yes

No

Medicare

Yes

No

Disability benefits

Yes

No

Retirement benefits

Yes

No

U.S. state driver's license

Yes

No

Documenting your children as U.S. citizens

Yes

No

U.S. immigration benefits

Yes

No

Any other right or benefit that requires U.S. citizenship and/or proof of residence
in the United States. (If "Yes," specify below)

Yes

No

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No

Yes

Address

Right/Benefit

Yes

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8. Other Nationalities
8(a) Are you a national or citizen of any other country other than the United States?
If "Yes," list the country/countries and indicate how you acquired that nationality.
Country of Other Nationality

Manner of Acquisition
(How you acquired)

Yes

No

Date of Acquisition
(mm-dd-yyyy)

At Birth
By Marriage
By Naturalization
At Birth
By Marriage
By Naturalization
At Birth
By Marriage
By Naturalization
At Birth
By Marriage
By Naturalization

PART I-B - OATH OF RENUNCIATION
You must complete PART I-B, items 9-12 (and PART I-A and PART II) if your request for a Certificate of Loss of
Nationality of the United States is based on taking an oath of renunciation before a diplomatic or consular officer of
the United States in a foreign country. Note: DO NOT complete this form if you are requesting a CLN based on taking
an oath of renunciation while in the United States under INA 349(a)(6). Contact the Department of Homeland Security
for information about taking an oath of renunciation while in the United States.
9. Request. Are you requesting a Certificate of Loss of Nationality of the United States based on
taking an oath of renunciation of U.S. nationality before a U.S. diplomatic or consular officer in
a foreign country?
If "Yes," complete this section, PART I-B. If "No," you are not required to complete PART I-B.

Yes

No

10. Appointment Location. What U.S. embassy or consulate do you plan to go to for your in-person interview and to
take the oath of renunciation? (U.S. Embassy X, country; or U.S. Consulate/Consulate General X, country)

11. Voluntariness. Respond to items 11(a)-(c), and explain your answers.
Yes
11(a) Are you choosing to take the oath of renunciation voluntarily?
11(b) Describe any factors that may have influenced your decision to take the oath of renunciation.

No

11(c) Describe whether you feel/felt pressured by any person and/or circumstance to take the oath of renunciation.

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12. Intent. What is your intent with respect to your U.S. nationality in taking the oath of renunciation?

PART I-C - NATURALIZATION IN A FOREIGN STATE
You must complete PART I-C, items 13-16 (and PART I-A and PART II-A, -B, and -D) if your request for a Certificate
of Loss of Nationality of the United States is based on naturalizing in a foreign state.
13. Request. Are you requesting a CLN based on naturalizing in a foreign state?

Yes

No

If "Yes," please respond to items 13-16. If "No," you are not required to complete this section, PART I-C.
14. Details. Respond to items 14(a)-(e).
14(a) Name of the foreign state of naturalization.
14(b) Date of naturalization (mm-dd-yyyy).
14(c) Place of naturalization.
14(c)(i) Where were you when you naturalized, in what country?
14(c)(ii) If you were in the United States when you naturalized, have you taken up
residence in a foreign country listed in 14(a)?

Yes

No

If "Yes," when did you depart the United States to take up residence in the
foreign country? (mm-dd-yyyy)
14(d) Method. By what means, under what law, and/or in what kind of proceeding, were you
naturalized as a national of the foreign state listed in 14(a)? (For example, did you become a
national by marriage to a national of the foreign state?)
14(e) Additional Information. Describe your decision to naturalize in a foreign state, including but
not limited to: (i) whether you knew you were a U.S. citizen at the time you naturalized in the
foreign state listed in 14(a); and (ii) when and how you became aware that naturalizing in a
foreign state could be a potentially expatriating act under U.S. law.

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15. Voluntariness. Respond to items 15(a)-(c) and explain your answers.
15(a) Did you naturalize in the foreign state listed in 14(a) voluntarily?
15(b) Describe any factors that may have influenced your decision to naturalize in the
foreign state listed in 14(a).

Yes

No

15(c) Describe whether you felt pressured by any person and/or circumstance to naturalize
in the foreign state listed in 14(a).

16. Intent. What was your intent with respect to your U.S. nationality at the time you naturalized in the foreign state
listed in 14(a)?

PART I-D - OATH OF ALLEGIANCE TO A FOREIGN STATE
You must complete PART I-D, items 17-20 (and PART I-A and PART II-A, -B, and -D) if your request for a Certificate
of Loss of Nationality of the United States is based on taking an oath of allegiance to a foreign state. NOTE: You may
be asked to provide a copy of the oath.
17. Request. Are you requesting a Certificate of Loss of Nationality of the United States based
on taking an oath of allegiance to a foreign state?

Yes

No

Yes

No

Yes

No

If "Yes," complete PART I-D. If "No," you are not required to complete this section, PART I-D.
18. Details. Respond to items 18(a)-(e).
18(a) Name of foreign state to which you made an oath of allegiance.
18(b) Date of oath (mm-dd-yyyy).
18(c) Place of oath.
18(c)(i) Where did you take the oath, in what country?
18(c)(ii) If you were in the United States when you took the oath, have you taken up
residence in a foreign country?
If "Yes", when did you depart the United States to take up residence in the
foreign country? (mm-dd-yyyy).
18(d) Nationality. Were you a national of the foreign state listed in 18(a) at the time you took
the oath of allegiance?
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18. Details. (Continued)
18(e) Additional Information. Describe your decision to take an oath of allegiance to a foreign
state, including but not limited to: (i) whether you knew you were a U.S. citizen at the time you
took an oath of allegiance to the foreign state listed in 18(a); (ii) when and how you became
aware that taking an oath of allegiance to a foreign state could be a potentially expatriating act
under U.S. law; and (iii) indicate under what law, for what purpose, and/or in what kind of
proceeding, you took an oath of allegiance to the foreign state listed in 18(a).

19. Voluntariness. Respond to items 19(a)-(c) and explain your answers.
19(a) Did you take an oath of allegiance to the foreign state listed in 18(a) voluntarily?
19(b) Describe any factors that may have influenced your decision to take an oath of
allegiance to the foreign state listed in 18(a).

Yes

No

19(c) Describe whether you felt pressured by any person and/or circumstance to take an
oath of allegiance to the foreign state listed in 18(a).

20. Intent. What was your intent with respect to your U.S. nationality at the time you took an oath of allegiance to the
foreign state listed in 18(a)?

PART I-E - SERVICE IN THE ARMED FORCES OF A FOREIGN STATE
You must complete PART I-E, items 21-24 (and PART I-A and PART II-A, -B, and -D) if your request for a Certificate
of Loss of Nationality of the United States is based on service in the armed forces of a foreign state.
21. Request. Are you requesting a Certificate of Loss of Nationality of the United States based
on service in the armed forces of a foreign state?

Yes

No

If "Yes," complete PART I-E. If "No," you are not required to complete this section, PART I-E.
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22. Details of Service. Respond to items 22(a)-(g). Attach additional pages if necessary. Attach orders (entry, service,
discharge) if applicable.
22(a) Name of foreign state in whose armed forces you served.
22(b) Dates of service (mm-dd-yyyy).
22(c) Place of service.
22(c)(i) Where did you serve, in what country/countries?
22(c)(ii) If you were in the United States when you served in the armed forces of the
foreign state listed in 22(a), have you taken up residence in a foreign country?

Yes

No

If "Yes," when did you depart the United States to take up residence in the
foreign country? (mm-dd-yyyy)
22(d) Branch of armed forces in which you served.
22(e) Rank(s) held. Include highest rank and dates (mm-dd-yyyy)
22(f) Responsibilities. List your responsibilities, functions, duties, and activities engaged in during your service.

22(g) Additional Information. Describe your decision to serve in the armed forces in the foreign
state listed in 22(a), including but not limited to: (i) whether you knew you were a U.S. citizen at
the time you served in the armed forces of the foreign state listed in 22(a); and (ii) when and how
you became aware that serving in the armed forces of a foreign state could be a potentially
expatriating act under U.S. law.

23. Voluntariness. Respond to items 23(a)-(c) and explain your answers.
23(a) Did you serve in the armed forces of the foreign state listed in 22(a) voluntarily?
23(b) Describe any factors that may have influenced your decision to serve in the armed
forces of the foreign state listed in 22(a).

Yes

No

23(c) Describe whether you felt pressured by any person and/or circumstance to serve in
the armed forces of the foreign state listed in 22(a).

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24. Intent. What was your intent with respect to your U.S. nationality at the time you served in the armed forces of the
foreign state listed in 22(a)?

PART I-F - EMPLOYMENT IN THE GOVERNMENT OF A FOREIGN STATE
You must complete PART I-F, items 25-28 (and PART I-A and PART II-A, -B, and -D) if your request for a Certificate of
Loss of Nationality of the United States (CLN) is based on accepting, having served in, or serving in, or performing the
duties of any office, post, or employment with the government of a foreign state.
25. Request. Are you requesting a CLN based on employment with the government of a foreign
state?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If "Yes," complete PART I-F. If "No," you are not required to complete this section, PART I-F.
26. Details of Employment. Respond to items 26(a)-(i).
26(a) Name of foreign state.
26(b) Dates of service (mm-dd-yyyy).
26(c) Place of service.
26(c)(i) Where did you serve, in what country/countries?
26(c)(ii) If you were in the United States, have you taken up residence in a foreign
country?
If "Yes," when did you depart the United States to take up residence in the
foreign country? (mm-dd-yyyy)
26(d) Branch/Office/Agency served in.
26(e) Position(s) held, including dates (mm-dd-yyyy).
26(f) Responsibilities. List your responsibilities, duties, functions, and activities engaged in.

26(g) Nationality. Were you a national of the foreign state listed in 26(a) at the time you
accepted or served in the position?
26(h) Oath of Allegiance. Were you required to take an oath of allegiance to hold the position?
If "Yes," were you a national of the foreign state listed in 26(a) at the time you took the
oath of allegiance?
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26. Details of Employment. (Continued)
26(i) Additional Information. Describe your decision to accept, serve in, or perform the duties of
any position with the government of the foreign state listed in 26(a), including but not limited to: (i)
whether you knew you were a U.S. citizen at the time you accepted, served in, or performed the
duties of any position with the government of the foreign state listed in 26(a); and (ii) when and
how you became aware that accepting, serving in, or performing the duties of any position with
the government of a foreign state could be a potentially expatriating act under U.S. law.

27. Voluntariness. Respond to items 28(a)-(c) and explain your answers.
27(a) Did you accept, serve in, or perform the duties of any position in the government of
the foreign state listed in 26(a) voluntarily?
27(b) Describe any factors that may have influenced your decision to accept, serve in, or
perform the duties of any position in the government of the foreign state listed in 26(a).

Yes

No

27(c) Describe whether you felt pressured by any person and/or circumstance to accept,
serve in, or perform the duties of any position with the government of the foreign state
listed in 26(a).

28. Intent. What was your intent with respect to your U.S. nationality at the time you accepted, or during your service in
the position with the government of the foreign state listed in 26(a)?

PART II - ATTESTATIONS UNDER OATH OR BY AFFIRMATION
DO NOT COMPLETE PART II OR SIGN THIS FORM UNTIL YOU ARE IN PERSON BEFORE A U.S. DIPLOMATIC
OR CONSULAR OFFICER IN A FOREIGN COUNTRY
Oath of Renunciation. You must complete all of PART II in-person before a U.S. diplomatic or consular officer in a
foreign country if you are requesting a Certificate of Loss of Nationality of the United States (CLN) based on taking the
oath of renunciation before a U.S. diplomatic or consular officer in a foreign country under Immigration and Nationality
Act section 349(a)(5) and listed on Instruction page 2 of 5 of this form.
Other Acts. You must complete PART II-A, -B, and -D in-person before a U.S. diplomatic or consular officer in a
foreign country if you are requesting a Certificate of Loss of Nationality of the United States (CLN) based on
performance of an act specified in Immigration and Nationality Act section 349(a)(1)-(4) and listed on Instruction page 2
of 5 of this form.
Note: Your answers on this form will become part of the official record in your case. Before signing this form, you may
wish to consult an attorney. Please review your responses 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 U.S.
nationality status and to your intention with respect to your U.S. nationality, you may attach more pages with that
information.
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PART II-A - STATEMENT OF UNDERSTANDING CONCERNING DETERMINATION OF LOSS OF U.S. NATIONALITY
I (insert name),

, understand that:

1. I have the right to relinquish my United States nationality.
2. If I request a Certificate of Loss of Nationality of the United States (CLN) under Immigration and Nationality Act
(INA) section 349(a)(1)-(5), and if the U.S. Department of State (the Department) approves my request and
issues a CLN in my name, the Department's finding constitutes a final agency determination of loss of U.S.
nationality.
3. The Department may only approve my request for a CLN if it determines that I have performed a potentially
expatriating act voluntarily without force, compulsion or undue influence placed upon me by any person, and
with the intent to relinquish my United States nationality.
4. If the Department approves my request for a CLN and issues a CLN in my name, I will become a foreign
national with respect to the United States, subject to all laws and procedures of the United States pertaining to
foreign nationals regarding entry and lawful presence in the United States.
5. If the Department approves my request for a CLN and issues a CLN in my name, and I do not possess the
nationality/citizenship of any country other than the United States, I may become stateless and may face
extreme difficulties traveling internationally, entering most countries, and maintaining a place to reside.
6. If the Department approves my request for a CLN and issues a CLN in my name, the finding of loss of U.S.
nationality may not prevent my involuntary return to the United States if I am found deportable by a foreign
country.
7. If the Department approves my request for a CLN and issues a CLN in my name, the finding of loss of U.S.
nationality may not affect my U.S. military or Selective Service status, if any. I understand that any
questions in this area must be resolved with the appropriate agencies.
8. If the Department approves my request for a CLN and issues a CLN in my name, the finding of loss of U.S.
nationality may not exempt me from prosecution in the United States.
9. If the Department approves my request for a CLN and issues a CLN in my name, the finding of loss of U.S.
nationality may not exempt me from extradition to the United States.
10. If the Department approves my request for a CLN and issues a CLN in my name, the finding of loss of U.S.
nationality may not relieve me of any United States income tax or other tax obligations. I understand that I must
contact the United States Internal Revenue Service for information related to any U.S. tax obligations. Further, I
understand that if the Secretary of the Department of Homeland Security determines that I relinquished my U.S.
nationality for tax avoidance purposes, I may be ineligible to receive a U.S. visa and ineligible to be admitted to
the United States as provided by INA section 212(a)(10)(E).
11. If the Department approves my request for a CLN and issues a CLN in my name, I will no longer be able to
transmit U.S. nationality to my children born abroad after the effective date of loss of nationality indicated on the
CLN.
12. The serious and irrevocable nature of a final determination of loss of nationality has been explained to me by the
(Vice) Consul at U.S Embassy/Consulate/ Consulate General (Circle one) ______________________________
(Specify), and I fully understand its consequences.

I (insert name), __________________________________________________ swear ___ affirm ___ (check one)
that I have: read ___ had read to me ___ (check one) this statement in
the _____________________________________ (specify language) language and fully understand its contents.
Signature
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Signature Date (mm-dd-yyyy)
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PART II-A - STATEMENT OF UNDERSTANDING (CONTINUED)
CONSULAR OFFICER'S ATTESTATION
__________________________________________________ (Name) appeared personally and
read ___ / had read to them___ (check one) this Statement of Understanding after my explanation of its meaning
and signed this statement under oath/affirmation before me this ______ day of ______ month, ______ year.

Consul of the United States of America

SEAL
NOTE: If you wish to request a Certificate of Loss of Nationality of the United States (CLN), please proceed to
PART II-B below. You may choose to request a CLN based on the act described in PART I, as indicated in your
responses to this Questionnaire.
PART II-B - STATEMENT OF VOLUNTARINESS AND INTENT TO RELINQUISH U.S. NATIONALITY
Subscribed and Sworn
I (insert name), _________________________________________________,
performed ___ will perform ___ (check one)
the potentially expatriating act described in PART I (check one):
PART I-B

PART I-C

PART I-D

PART I-E

PART I-F

voluntarily and with the intention of relinquishing U.S. nationality.

Signature

Signature Date (mm-dd-yyyy)

Consul of the United States of America

Date (mm-dd-yyyy)

SEAL
NOTE: If you wish to request a Certificate of Loss of Nationality of the United States (CLN) based on taking an
oath of renunciation of U.S. nationality before a U.S. diplomatic or consular officer in a foreign country, please
proceed to PART II-C. If not, please proceed to PART II-D.
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PART II-C - OATH/AFFIRMATION OF RENUNCIATION OFNATIONALITY OF UNITED STATES
U. S. Department of State

OATH/AFFIRMATION OF RENUNCIATION OF
NATIONALITY OF UNITED STATES
at
(Embassy/Consulate)

ss:

(Country)

I,

, a national of the United States,

Name (Print Full Name)

solemnly swear/affirm that I was born at
,

, on

(State or Country)

(Province or County)

,

(City or Town)
Date (mm-dd-yyyy)

That I formerly resided in the United States at:
(Street Address)
(City, State and ZIP Code)

That I am a national of the United States by virtue of:
Birth in United States or Abroad to U.S. Parent(s)
Naturalization

Date of Naturalization
Date (mm-dd-yyyy)

(If naturalized, list the name, city, and state of the U.S. court or field office of U.S. Citizenship and
Immigration Services (formerly Immigration and Naturalization Service) before which naturalization was
granted.)
(Name of Court or Field Office)
(City, State)

I desire and hereby make a formal renunciation of my U.S. nationality, as provided by section 349(a)(5) of the
Immigration and Nationality Act of 1952, as amended, and pursuant thereto, I hereby absolutely and entirely
renounce my U.S. nationality together with all rights and privileges and all duties and allegiance and fidelity
thereunto pertaining. I make this renunciation intentionally, voluntarily, and of my own free will, free of any duress
or undue influence.
(Signature)

Subscribed and sworn/affirmed to before me this
at the

(Embassy/Consulate)

day of

,
(Place)
(Signature of Officer)
(Typed Name of Officer)

(Title of Officer)

SEAL
NOTE: If the U.S. Department of State approves my request for a Certificate of Loss of Nationality, the effective
date of loss is the date of performance of the act/fulfillment of all legal requirements.
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PART II-D - ATTESTATION TO CORRECTNESS AND COMPLETENESS
This Questionnaire and attachments will become a U.S. Department of State record with respect to your request for a
Certificate of Loss of Nationality of the United States (CLN) under Immigration and Nationality Act (INA) section
349(a)(1)-(5). Before signing this form, read over your answers to make certain that they are as complete and accurate
as possible. Provide any additional information you believe relevant to your request for a CLN, using additional paper if
necessary. You may wish to consult an attorney.
I (insert name), _________________________________________________, attest that all information, including
supporting documentation, submitted by me in connection with this Questionnaire is true and complete to the best of my
knowledge and belief.
Signature

Signature Date (mm-dd-yyyy)

Consul of the United States of America

Date (mm-dd-yyyy)
SEAL
WARNING: False statements made knowingly and willfully on this form, in affidavits, and/or other supporting
documents submitted therewith are punishable by fine or imprisonment under 18 U.S.C. 1001.
PRIVACY ACT STATEMENT
AUTHORITIES: The information on this form is requested under the authority of Immigration and Nationality Act (INA)
section 104 (8 U.S.C. 1104); INA section 349 (8 U.S.C. 1481); INA section 350 (8 U.S.C. 1482) [Repealed]; INA section
351 (8 U.S.C. 1483); INA section 356 (8 U.S.C. 1488); INA section 358 (8 U.S.C. 1501); and 22 CFR PART 50,
Subpart C.
PURPOSE: The principal purpose of collecting this information is for use in determining whether a person who is
requesting a Certificate of Loss of Nationality of the United States based on performance of a potentially expatriating act
as defined in INA section 349(a)(1)-(5) or other applicable statutes has met all legal requirements necessary for the U.S.
Department of State to approve the request and issue a Certificate of Loss of Nationality of the United States in the
requester's name.
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. If a Certificate of Loss of Nationality of the United States is issued,
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. For a more detailed listing of the routine uses to which this information may be put, please see
the Department of State's Prefatory Statement of Routine Uses (Public Notice 6290 of July 15, 2008) and the listing of
routine uses set forth in the System of Records Notices for Overseas Citizen Services Records and Other Overseas
Records (State-05) and Passport Records (State-26) published in the Federal Register.
DISCLOSURE: Although furnishing the information is voluntary, individuals may not be eligible for a Certificate of Loss
of Nationality of the United States if they do not provide the requested information.
PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 43 minutes per response, including time
required for searching existing data sources, gathering 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: CA/OCS/ACS, DEPARTMENT OF STATE, SA-17, 10th FLOOR,
Washington, D.C. 20522.
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