1405-0178 Supporting Statement

SUPPORTING STATEMENT FOR
PAPERWORK REDUCTION ACT SUBMISSION

QUESTIONNAIRE – LOSS OF NATIONALITY; ATTESTATIONS
OMB Number 1405-0178

A. JUSTIFICATION

1. Why is this collection necessary and what are the legal statutes that allow this?

The information on this form is requested under the authority of Immigration and Nationality Act (INA) § 104 (8 U.S.C. 1104); INA § 349 (8 U.S.C.1481); INA § 350 (8 U.S.C. 1482) [repealed]; INA § 351(8 U.S.C.1483); INA § 356 (8 U.S.C.1488); INA § 358 (8 U.S.C.1501); and 22 CFR PART 50 – Subpart C.

The Secretary of State is charged with “the determination of nationality of a person not in the United States,” and “shall establish such regulations; prescribe such forms of reports, entries and other papers; issue such instructions; and perform such other acts as he deems necessary for carrying out such provisions” in accordance with INA § 104. The Secretary is responsible for reviewing and approving or denying a request for a Certificate of Loss of Nationality of the United States (Certificate of Loss of Nationality) under INA § 349(a)(1)-(5) in accordance with INA § 358. INA § 349(b) places the burden of proof on the person requesting a Certificate of Loss of Nationality to establish the performance of the requisite act and satisfaction of all conditions before the U.S. Department of State (Department) may have a legal basis to approve the request and issue a Certificate of Loss of Nationality in the person’s name. The Department must request relevant information to guide its determination.

The changes to the DS-4079 are necessary to help ensure that the Department’s adjudication of a request for a Certificate of Loss of Nationality is based on sufficient information and adheres to the principles of U.S. Supreme Court precedent requiring that an individual perform a potentially expatriating act voluntarily and with the intent to relinquish U.S. nationality, such that the Department has a legal basis to issue a Certificate of Loss of Nationality in the requester’s name. These changes are also necessary to eliminate the fact or even the appearance of “arbitrary and capricious” administration of the loss of nationality statutes.

To ensure uniform administration of the loss of nationality statutes under the Secretary’s purview and to standardize the process for requesting a Certificate of Loss of Nationality, the Department is revising the instructions and information collection requested on the current form DS-4079, OMB No. 1405-0178, “Request for Determination of Possible Loss of U.S. Nationality,” including changing the title to “Questionnaire – Loss of Nationality; Attestations” (Questionnaire/Attestations), and incorporating in PART II of the revised DS-4079, the contents of current form DS-4081, “Statement of Understanding Concerning the Consequences and Ramifications of Renunciation or Relinquishment of U.S. Nationality,” as revised, and the contents of the current form DS-4080, “Oath/Affirmation of Renunciation of Nationality of the United States,” as revised. The DS-4081 does not require OMB approval as it is not an information collection covered by the Paperwork Reduction Act; however, in keeping with its efforts to standardize the process for requesting a Certificate of Loss of Nationality and to reduce the possibility of error, the Department seeks to consolidate all necessary forms in one place.

The changes will benefit those requesting a Certificate of Loss of Nationality by simplifying and consolidating the content of all required forms into one form, eliminating unnecessary information requests, and providing clear and detailed instructions about the process for requesting a Certificate of Loss of Nationality. Further, the Department intends to provide official translations of the revised form DS-4079 into nine languages (for the most frequently requested languages and for high volume posts) and to provide official translations in additional languages upon request.

2. What business purpose is the information gathered going to be used for?

The principal purpose of gathering this information is to determine if the individual who is requesting a Certificate of Loss of Nationality of the United States has performed a potentially expatriating act as defined in INA section 349(a)(1)-(5)(8 U.S.C. 1481) and other applicable statutes voluntarily and with the intention of relinquishing U.S. nationality, such that the Department has a legal basis to issue a Certificate of Loss of Nationality in their name. The information may also be used in conducting an administrative review of a prior Department decision to issue a Certificate of Loss of Nationality in an individual’s name, or to deny a request for a Certificate of Loss of Nationality.

3. Is this collection able to be completed electronically (e.g. through a website or application)?

The revised form DS-4079 Questionnaire/Attestations will be available electronically as a fillable form online at eforms.gov. A person who requests a Certificate of Loss of Nationality may complete, but not sign, the applicable parts of the Questionnaire in advance of the required in person appearance and interview before a U.S. diplomatic or consular officer abroad. The requester is required to print and submit the hard copy and sign the relevant parts of PART II of the form, “Attestations under Oath or by Affirmation,” in person before a U.S. diplomatic or consular officer in a foreign country.

Additionally, the Department is in the process of updating its Foreign Affairs Manual to permit the required initial interview to be conducted electronically (by email) for most requesters and at most U.S. embassies and consulates (post(s)), with procedural safeguards to ensure the availability of in-person and/or telephonic first interview if necessitated by the circumstances. Although currently, post may use a Department cleared “intake form” that requests basic information, the Department plans to transition to use of the revised DS-4079, Questionnaire, once approved, to further standardize procedures across all posts.

4. Does this collection duplicate any other collection of information?

The revised form DS-4079 does not duplicate any other information request aside from the basic required information (name, date of birth, place of birth, etc.).

5. Describe any impacts on small business.

Only an individual person may request a Certificate of Loss of Nationality and complete the required forms; small businesses do not use this form and consequently, there is no impact on small businesses.

6. What are consequences if this collection is not done?

The Department requires this information to help determine if the individual who is requesting a Certificate of Loss of Nationality of the United States has performed a potentially expatriating act as defined in INA § 349(a)(1)-(5)(8 U.S.C. 1481) and other applicable statutes voluntarily and with the intention of relinquishing U.S. nationality, such that the Department has a legal basis to issue a Certificate of Loss of Nationality in their name. Additionally, the revised form, DS-4079 Questionnaire/Attestations, PART II, includes the oath of renunciation of U.S. nationality which must be taken by those requesting a Certificate of Loss of Nationality under INA § 349(a)(5) to fulfill the statutory conditions of that section. Finally, the Department may use the information collection during reconsideration of a previous decision to issue a Certificate of Loss of Nationality or to deny a request for one.

7. Are there any special collection circumstances?

No special circumstances exist.

8. Document publication (or intent to publish) a request for public comments in the Federal Register

The Department published a notice in the Federal Register on July 19, 2023 (88 FR 46359) soliciting public comments. As of September 25, 2023, the Department has received seven public comments addressing multiple topics.

Topic 1: Remote process.

Five commenters stated that the process for requesting a Certificate of Loss of Nationality of the United States (CLN) should be remote with no requirement to appear in person at a U.S. embassy or consulate. As an alternative, one commenter suggested there be only one in-person interview.

Response. In response to the comments about offering a remote process or one in-person interview only, in light of the gravity and implications of a decision to seek a Certificate of Loss of Nationality of the United States (CLN), which, if issued by the Department of State, constitutes a final and irrevocable determination of loss of U.S. nationality (subject to administrative and/or judicial appeal), the Department does not intend to remove the in-person interview requirement at this time. However, as noted above, the Department is in the process of updating its Foreign Affairs Manual to permit the required initial interview to be conducted electronically (by email) for most requesters and at most U.S. embassies and consulates (post(s)), with procedural safeguards to ensure the availability of in-person and/or telephonic first interviews if necessitated by the circumstances.

Topic 2: Estimate of Cost of Travel to U.S Embassy or Consulate.

One commenter stated that a cost of travel estimate should be included in this Supporting Statement, noting that the Supporting Statement for the last revision of the DS-4079 included such an estimate.

Response: Notwithstanding what may have been offered in the past, the Department has no realistic way to calculate the average distance a person requesting a Certificate of Loss of Nationality of the United States (CLN) may have to travel to one of the 249 U.S. embassies or consulates overseas for CLN services (or for any other service).

Topic 3: Fee for CLN Services.

3a. Fee too high.

Three commenters believe the fee for processing a request for a Certificate of Loss of Nationality of the United States (CLN) is too high, with one of the commenters stating that “the assertion that it costs $2350 to process a request for a [CLN] is not credible” and another stating that the fee is unjustified.

Response: As previously noted, the Department intends to undertake rulemaking to reduce the fee for Administrative Processing of Request for Certificate of Loss of Nationality of the United States (CLN), from $2,350 to $450, subject to review of public comments received in response to the notice of proposed rulemaking. The Department intends to address issues related to the fee for CLN services as part of that proposed rulemaking process as opposed to in this Paperwork Reduction Act submission.

3b. Delay in Reducing the Fee.

Four commenters noted that the Department indicated [in January 2023] its intent to undertake rulemaking to reduce the fee for Administrative Processing of Request for Certificate of Loss of Nationality of the United States (CLN), from $2,350 to $450 (subject to review of public comments received in response to the notice of proposed rulemaking) but that the fee has yet to be reduced.

Response: As previously noted, the Department intends to undertake rulemaking to reduce the fee for Administrative Processing of Request for Certificate of Loss of Nationality of the United States (CLN), from $2,350 to $450, subject to review of public comments received in response to the notice of proposed rulemaking. The Department intends to address issues related to the fee for CLN services as part of that proposed rulemaking process as opposed to in this Paperwork Reduction Act submission.

Response:

3c. Calculating the Fee.

One commenter provides extensive analysis, concluding that the calculation of the current fee for CLN services is flawed and that any proposed reduction of the fee for CLN services to $450 is arbitrary.

Response: As previously noted, the Department intends to undertake rulemaking to reduce the fee for Administrative Processing of Request for Certificate of Loss of Nationality of the United States (CLN), from $2,350 to $450, subject to review of public comments received in response to the notice of proposed rulemaking. The Department intends to address issues related to the fee for CLN services as part of that proposed rulemaking process as opposed to in this Paperwork Reduction Act submission.

3d. Fee Waiver.

One commenter requests a waiver of the fee for persons who may be financially burdened and for certain other U.S. citizens based on the length of time they have spent in the United States.

Response: As previously noted, the Department intends to undertake rulemaking to reduce the fee for Administrative Processing of Request for Certificate of Loss of Nationality of the United States (CLN), from $2,350 to $450, subject to review of public comments received in response to the notice of proposed rulemaking. The Department intends to address issues related to the fee for CLN services as part of that proposed rulemaking process as opposed to in this Paperwork Reduction Act submission.

Topic 4: Discrepancy in Cost to Federal Government.

One commenter notes the seeming discrepancy between the Department’s response to item 14 (cost incurred by the Federal Government) in the 2020 Supporting Statement for the DS-4079 and its proposed revised response to item 14 in the current (2023) Supporting Statement.

Response: As indicated in its response to item 14 in the 2020 and the 2023 Supporting Statements, the total cost to the Federal Government for reviewing the responses to this information collection is determined in large part by calculating average hours spent reviewing the DS-4079 form times the average compensation cost per hour. Although the average number of hours for reviewing the DS-4079 in 2020 may have been even significantly less than what is indicated for the current information collection, there is at least one reason for the seeming discrepancy: The current proposed DS-4079, “Questionnaire -Loss of Nationality; Attestations,” now incorporates into one form all the forms that a person who requests a Certificate of Loss of Nationality of the United States (CLN) under Immigration and Nationality Act (INA) 349(a)(1)-(5) must complete, including the DS-4080, “Oath/Affirmation of Renunciation of Nationality of the United States,” and the DS-4081, “Statement of Understanding of the Consequences and Ramifications of Renunciation or Relinquishment of U.S. Nationality,” currently standalone documents not accounted for in the five-minute period estimated for consular personnel review of the DS-4079 “Request for Determination of Possible Loss of United States Nationality,” of 2020. Finally, as noted in item 14 of the current Supporting Statement, because the revised DS-4079 incorporates two other forms (the current DS-4081 and DS-4080) the review time of the DS-4079 likely will increase and therefore the cost calculations above [in item 14] are estimates only and likely will need to be adjusted.

Topic 5: Alternate Process for Certain Persons

One commenter believes the Department should offer a shorter process for requesting a Certificate of Loss of Nationality of the United States for certain U.S. citizens based in part on the length of their stay in the United States.

Response: For the integrity and the equitable administration of the process, among other reasons, the Department does not intend to provide an alternate process for requesting a Certificate of Loss of Nationality of the United States. However, as noted above, the Department is in the process of updating its Foreign Affairs Manual to permit the required initial interview to be conducted electronically (by email) for most requesters and at most U.S. embassies and consulates (post(s)), with procedural safeguards to ensure the availability of in-person and/or telephonic first interview if necessitated by the circumstances.

Topic 6: Efficiency/Length of Time.

One commenter stated that the process is inefficient and increasingly long, taking several months.

Response: The length of time for processing a request for a CLN is due to several factors unrelated to the revision of the DS-4079. As noted above, to ensure uniform administration of the loss of nationality statutes under the Secretary’s purview and to standardize the process for requesting a Certificate of Loss of Nationality, the Department is revising the instructions and information collection requested on the current form DS-4079, OMB No. 1405-0178, “Request for Determination of Possible Loss of U.S. Nationality,” including changing the title to “Questionnaire – Loss of Nationality; Attestations” (Questionnaire/Attestations), and incorporating in PART II of the revised DS-4079, the contents of current form DS-4081, “Statement of Understanding Concerning the Consequences and Ramifications of Renunciation or Relinquishment of U.S. Nationality,” as revised, and the contents of the current form DS-4080, “Oath/Affirmation of Renunciation of Nationality of the United States,” as revised. The DS-4081 does not require OMB approval as it is not an information collection covered by the Paperwork Reduction Act; however, in keeping with its efforts to standardize the process for requesting a Certificate of Loss of Nationality and to reduce the possibility of error, the Department seeks to consolidate all necessary forms in one place.

The changes will benefit those requesting a Certificate of Loss of Nationality by simplifying and consolidating the content of all required forms into one form, eliminating unnecessary information requests, and providing clear and detailed instructions about the process for requesting a Certificate of Loss of Nationality. Further, the Department intends to provide official translations of the revised form DS-4079 into nine languages (for the most frequently requested languages and for high volume posts) and to provide official translations in additional languages upon request.

Additionally, the Department is in the process of updating its Foreign Affairs Manual to permit the required initial interview to be conducted electronically (by email) for most requesters and at most U.S. embassies and consulates (post(s)), with procedural safeguards to ensure the availability of in-person and/or telephonic first interview if necessitated by the circumstances. Although currently, post may use a Department cleared “intake form” that requests basic information, the Department plans to transition to use of the revised DS-4079, Questionnaire, once approved, to further standardize procedures across all posts.

Topic 7: Revisions to Form DS-4079.

One commenter provided suggested edits to the Form DS-4079 itself:

1. In the instructions for question 5 and in question 5, I suggest changing “U.S. citizens parent(s)” to “U.S. national parent(s)”, because children born abroad to non-citizen U.S. nationals can also acquire U.S. nationality at birth.

Response: The Department will change “U.S. citizen parent(s)” to “U.S. national parent(s).”

2. I suggest placing fields 5.a and 5.b inside the answer about naturalization, rather than in separate blocks, because these fields only apply to people who acquired U.S. nationality by naturalization.

Response: The Department is considering this format change.

3. I suggest removing question 7.a.i, because it’s redundant with question 7.a.iii.

Response: Item 7 has been reformatted and revised as indicated in item 15 of this Supporting Statement.

Item 7(a)(i) asks, “Do you reside in the United States? If ‘Yes,’ list the address.” Item7(a)(iii) asks, “Do you maintain a residence or residences in the United States? If ‘Yes,’ provide the address(es) and dates of stay, if any.” The first question asks whether the person is currently residing in the United States; the second question asks if the person maintains a residential property or properties in the United States. A person can own residential property in the United States and not be residing in it. While there is no law against residential property ownership – if the person does maintain such a residence and stays there frequently (but not necessarily solely) this may be inconsistent with a stated intent to relinquish U.S. nationality and the rights and benefits it entails.

Other suggested edits to Item 7, Ties to the United States:

4. Section 7.d should be titled “Driver’s license”, not “Passport”. I also suggest changing question 7.d.i to “Do you have an unexpired U.S. driver’s license?”, similar to 7.c.i, if expired documents are not relevant for this question. I also suggest generalizing this section to driver’s license or identification card.

5. Question 7.e.i is vague, because voting is not a continuous process. People choose whether or not to vote in each election separately. In addition, it’s unclear whether “vote in the United States” includes voting in U.S. elections from abroad by absentee ballot, which is how most respondents to this form would vote. So I suggest changing this question to “Have you ever voted in a U.S. election?”

6. In question 7.g.i, I suggest changing “certain 401K benefits” to “certain retirement benefits”, as this more general term would also include U.S. military retirement pay that requires U.S. citizenship.

Response: Item 7 has been revised and reformatted and now consists only of subparts 7(a) Residence and 7(b) Rights/Benefits. The categories listed in 7(b) are deliberately broad. The rationale for this question is to obtain as full a picture as possible of the person's ties/involvement with the United States in order to aid in assessing the credibility of a stated intent to relinquish U.S. nationality. The questions in 7(b) are intentionally open ended - the information requested is cumulative and not necessarily dispositive on its own but decidedly relevant.

The Department will consider further edits to item 7 in accordance with public comments.

7. I suggest removing question 8.a.i, because it’s redundant with 7.a.i and 7.a.iii, and it confuses the “if yes” below the question. Respondents should list the countries of other nationalities regardless of where they reside.

Response: Item 8 has been revised to remove this subpart.

8. Questions 15.c.i and 15.c.ii, 19.c.i and 19.c.ii, 23.c.i and 23.c.ii, 27.c.i and 27.c.ii are redundant. In each section, I suggest keeping only one of these two questions.

Response: These questions are now items 14(c)(i) and (ii), 18(c)(i) and (ii), 22(c)(i) and (ii), and 26(c)(i) and (ii). Both questions are required to determine the effective date of a possible determination of loss of nationality. If the person performed the potentially expatriating act while in the United States, the restriction on loss of nationality specified in Immigration and Nationality Act section 351(a)(8 U.S.C. 1483) would apply.

9. In questions 15.c.ii, 15.e, 19.e, 23.g, 27.i, I suggest changing “citizen” to “national”, because it’s more general. There are countries, including the United States, where people can be nationals but not citizens.

Response: The Department will change “citizen” to “national” where appropriate.

The remaining comments request statutory and/or regulatory changes to U.S. taxation law, financial reporting requirements, and the requirement that the Department notify the interagency upon issuance of a Certificate of Loss of Nationality of the United States. and are not related to the revision of this form.

9. Are payments or gifts given to the respondents?

No payment or gift is provided to respondents.

10. Describe assurances of privacy/confidentiality.

There are no promises of confidentiality to the respondents.

11. Are any questions of a sensitive nature asked?

No sensitive questions are asked.

12. Describe the hour time burden and the hour cost burden on the respondent needed to complete this collection.

Approximately 4,850 U.S. citizens worldwide will submit the DS Form 4079 annually to a U.S. diplomatic or consular officer abroad in connection with a request for a Certificate of Loss of Nationality of the United States. The average total annual hour burden to complete the DS Form 4079 for all applicants is 3,475 hours.

The annual hour burden on an applicant was determined by multiplying 4,850 by 43 minutes equaling 208,550 minutes. Then 208,550 minutes was divided by 60 minutes, to give an annual burden of 3,475 hours ((4,850 x 43)/60).

The overall hourly cost burden to the applicant is approximately $108,654. The hourly cost burden was determined to be $22.33, which is the average mean hourly civilian wage. $22.33/hr was multiplied by 1.4, resulting in a weighted hourly wage of $31.26/hr. $31.26/hr. was then multiplied by the 3,475 hourly annual burden, providing an overall hourly cost burden of approximately $108,654.

13. Describe the monetary burden to respondents (out of pocket costs) needed to complete this collection.

A U.S. citizen who requests a Certificate of Loss of Nationality under INA § 349(a)(1)-(5) must complete, but not sign, the DS-4079 Questionnaire/Attestations and bring it, along with any supporting documents, to the mandatory in-person interview with a U.S. diplomatic or consular officer. The requester may email the unsigned form or send the unsigned form via mail to the U.S. diplomatic mission before their interview. There are no required costs associated with delivering the form to a U.S. diplomatic mission before the in-person interview.

Currently the fee for administrative processing of a request for a Certificate of Loss of Nationality is $2,350. The Department will consider any necessary changes to this fee, as appropriate, in a future rulemaking. The administrative processing fee is collected when the requester and the U.S. diplomatic or consular officer sign the relevant sections of Part II of the DS-4079. There is no separate fee collected for completion of the relevant sections of Part I of a DS-4079.

14. Describe the cost incurred by the Federal Government to complete this collection.

The total cost to the Federal Government for reviewing the responses to this information collection is determined in large part by calculating average hours spent reviewing the DS-4079 form times the average compensation cost per hour. The Department expects to receive approximately 4,850 DS-4079 forms per year. On average each DS-4079 is reviewed for five minutes each by overseas Locally Employed Staff (LES) (4,850 respondents x $2.05 = $9,942.50), 20 minutes each by an overseas Foreign Service officer (4,850 x $26.40 = $128,040.00), and 15 minutes each by a domestic Foreign Service officer (4,850 x $17.40 = $84,390.00), and a domestic Civil Service officer (4,850 x $17.40 = $84,390.00). In certain cases, the form may also be reviewed by attorneys in the Office of Legal Affairs, Overseas Citizen Services Directorate, and in the Office of the Assistant Legal Adviser for Consular Affairs.

The cost to the Federal Government related to this service is $306,762.50 (9,942.50 + 128,040.00 + (84,390.00 x 2)).  To get the calculations above, the hourly rate for an overseas LES is $24.60, overseas Foreign Service officer is $79.20, domestic Foreign Service officer is $69.60, and a domestic Civil Service officer is $69.60.

These calculations are based on the internal to the Department of State position costs for LES and the internal Bureau of Budget and Planning New Position Cost Model for the respective Foreign Service and Civil Service employment categories.  The cost rates include fringe and overhead costs.

Because the revised DS-4079 incorporates two other forms (the current DS-4081 and DS-4080) the review time of the DS-4079 likely will increase and therefore the cost calculations above are estimates only and likely will need to be adjusted.

15. Explain any changes/adjustments to this collection since the previous submission

Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

This information collection DS-4079 has been reworked in its entirety in an effort to ensure uniform and constitutionally sound administration of the loss of nationality statutes under the Secretary’s purview, specifically, the potentially expatriating acts enumerated in Immigration and Nationality Act (INA) 349(a)(1)-(5); to delete outdated/irrelevant questions; to standardize the process for requesting a Certificate of Loss of Nationality to the greatest extent possible so that all U.S. embassies and consulates are using the same detailed instructions and requesting the same background and targeted information of any person requesting a Certificate of Loss of Nationality under INA 349(a)(1)-(5); and to help ensure that the Department has sufficient relevant information to discharge its obligation to determine whether to approve or deny the individual’s request for a Certificate of Loss of Nationality and, if approved, to issue a Certificate of Loss of Nationality in the individual’s name reflecting the effective date of loss of nationality.

The decision to also require persons requesting a Certificate of Loss of Nationality based on taking an oath of renunciation before a U.S. diplomatic or consular officer abroad under INA 349(a)(5), which accounts for about 99% of the requests processed by the Department and therefore accounts for the increase in number of annual respondents from 600 to 4,850, is primarily to standardize the manner in which the required information is collected from anyone who requests a Certificate of Loss of Nationality from the Department in a clear, streamlined, and transparent manner: as of now, post collects this information already from persons requesting a Certificate of Loss of Nationality under INA 349(a)(5), just in various ways not standardized across all posts.

The changes will benefit those requesting a Certificate of Loss of Nationality by simplifying and consolidating the content of all required forms into one form, eliminating unnecessary information requests, and providing clear and detailed instructions about the process for requesting a Certificate of Loss of Nationality that does not vary depending on the post providing the service.

Further, and critically, the Department intends to provide official translations of the revised form DS-4079 in nine languages (for the most frequently requested languages and for high volume posts) and to provide official translations in additional languages upon request.

The significant changes to the information collection include:

Changing the title of current form DS-4079, OMB No. 1405-0178, “Request for Determination of Possible Loss of U.S. Nationality,” to “Questionnaire – Loss of Nationality; Attestations” (Questionnaire/Attestations) to reflect the incorporation of other required forms;

Providing detailed instructions of the required steps in properly completing a request for a Certificate of Loss of Nationality, a non-exhaustive list of documents to be submitted; and instructions for each numbered item and part of the form. (The current form instructions provides little guidance and indicates that “most items are self-explanatory,” which is not likely to be helpful to individuals with limited English language proficiency.) The instructions on the revised form are also instructive for entry level officers and other officers who may not be familiar with the ins and outs of processing a request for a Certificate of Loss of Nationality.)

Reducing the number of items to which individuals must respond from 19 numbered items (current form) to 12.

[NOTE: Although there are 28 numbered items in PART I, a person is only required to respond to 8 “background” items (name, address, date, and place of birth, etc.) and to 4 items that are “targeted” to the specific section of law under which the person is requesting a Certificate of Loss of Nationality.]

Specifically, PART I has been divided into five subsections as follows:

PART I-A, “Background Information,” consisting of eight items, numbered 1-8, to which everyone who requests a Certificate of Loss of Nationality must respond;

PART I-B, “Oath of Renunciation,” consisting of four items, numbered 9-12, to which only persons requesting a Certificate of Loss of Nationality under INA 349(a)(5) must respond;

PART I-C, “Naturalization in a Foreign State,” consisting of four items, numbered 13-16, to which only persons requesting a Certificate of Loss of Nationality under INA 349(a)(1) must respond;

PART I-D, “Oath of Allegiance to a Foreign State,” consisting of four items, numbered 17-20, to which only persons requesting a Certificate of Loss of Nationality under INA 349(a)(2) must respond;

PART I-E, “Service in the Armed Forces of a Foreign State” consisting of four items, numbered 21-24, to which only persons requesting a Certificate of Loss of Nationality under INA 349(a)(3) must respond;

PART I-F, “Employment in the Government of a Foreign State,” consisting of four items, numbered 25-28, to which only persons requesting a Certificate of Loss of Nationality under INA 349(a)(4) must respond.

The revised DS-4079, PART II, “Attestations under Oath or by Affirmation,” contains four parts which are to be signed as applicable before a U.S. diplomatic or consular officer abroad at the final, mandatory in-person interview. PART II-A, -B, and -D must be completed by any individual requesting a Certificate of Loss of Nationality under INA 349(a)(1)-(5); PART II-C is only to be completed by an individual requesting a Certificate of Loss of Nationality based on taking an oath of renunciation of U.S. nationality before a U.S. diplomatic or consular officer abroad under INA 349(a)(5).

Specifically, PART II contains the following:

PART II-A, “Statement of Understanding Concerning Determination of Loss of U.S. Nationality, which incorporates the contents of current form DS-4081, “Statement of Understanding Concerning the Consequences and Ramifications of Renunciation or Relinquishment of U.S. Nationality,” as revised;

[NOTE: The DS-4081 does not require OMB approval as it is not an information collection covered by the Paperwork Reduction Act; however, in keeping with its efforts to standardize and streamline the process for requesting a Certificate of Loss of Nationality while reducing the possibility of error, the Department seeks to consolidate all necessary forms in one place.]

PART II-B, “Statement of Voluntariness and Intent to Relinquish U.S. Nationality;

PART II-C, “Oath/Affirmation of Renunciation of Nationality of the United States,” as revised, containing the contents of the current form DS-4080;

PART II-D, “Attestation to Correctness and Completeness.”

INFORMATION REQUESTED ON DS-4079

The information requested in each section of PART I is as follows:

PART I-A – BACKGROUND INFORMATION (Items 1-8)

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 at birth, indicate how 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).

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

(a) Last U.S. Passport Number

(b) Issued at (Place)

(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)

7. Ties to the United States.

7(a) Residence.

(i) Do you reside in the United States? Yes__ No__

If “Yes,” list your address. _______________________________

(ii) Have you ever resided in the United States? Yes__ No__

If “Yes,” provide the city, state, and dates of residence.

City/State	Dates: From/To (mm/yyyy to mm/yyyy)

(iii) Do you currently maintain a residence in the United States? Yes__ No__

If “Yes,” provide address(es) and dates of stay, if any.

Address	Dates of stay: From/To (mm/yyyy to mm/yyyy)

(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? Yes__ No__

If “Yes,” please list.

Right/Benefit	Check Yes or No
U.S. passport (unexpired)	Y ___ N___
Medical/Professional License(s)	Y ___ N___
Voting in U.S. elections	Y____ N____
Medicare	Y____ N____
Disability benefits	Y____ N____
Retirement benefits	Y ___ N___
U.S. state driver’s license	Y ___ N___
Documenting your children as U.S. citizens	Y ___ N___
U.S. immigration benefits	Y ___ N___
Any other right or benefit that requires U.S. citizenship and/or proof of residence in the United States	Y____ N___ (If “Yes,” specify below)

8. Other Nationalities.

(a) Are you a national or citizen of any other country besides the United States?

Yes __ No__

If “Yes,” list the country/countries and indicate how you acquired that nationality.

Country of Other Nationality	Manner of Acquisition (How you acquired)	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 (Items 9-12)

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 nationality 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. Contact the Department of Homeland Security for information about taking the oath of renunciation while in the United States.

9. Request. Are you 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? Yes No

If “Yes,” complete PART I-B. If “No,” you are not required to complete this section, PART I-B.

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.

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.

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

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

PART I-C NATURALIZATION IN A FOREIGN STATE (Items 13-16)

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 (CLN) is based on the naturalizing in a foreign state.

13. Request. Are you requesting a CLN based on naturalizing in a foreign state? Yes No

If “Yes,” complete PART I-C. 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 foreign state in which you naturalized.

14(b) Date of naturalization. (mm-dd-yyyy)

14(c) Place of naturalization.

14(c)(i) Where were you when you naturalized, what country?

14(c)(ii) If you were in the United States when you naturalized, 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)

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 country listed in 14(a)? (For example, did you become a national by marriage to a national of the foreign country listed in 14(a)?)

14(e) Additional Information. Describe your decision to naturalize in a foreign country, including but not limited to: (i) whether you knew you were a U.S. citizen at the time you naturalized in the foreign country listed in 14(a); and (ii) when and how you became aware that naturalizing in a foreign country could be a potentially expatriating act under U.S. law.

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? Yes No

15(b) Describe any factors that may have influenced your decision to naturalize in the foreign state listed in 14(a).

15(c) Describe whether you felt pressure by any person and/or circumstance to naturalize in the foreign country 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 item 14(a)?

PART I-D OATH OF ALLEGIANCE TO A FOREIGN STATE (Items 17-20)

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 (CLN) is based on the 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 CLN based on taking an oath of allegiance to a foreign state? 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? Yes No

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? Yes No

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 item 18(a); and (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.

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 item 18(a) voluntarily? Yes No

19(b) Describe any factors that may have influenced your decision to take an oath of allegiance to the foreign state listed in item 18(a).

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

PART I-E SERVICE IN THE ARMED FORCES OF A FOREIGN STATE (Items 21-24)

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 (CLN) is based on service in the armed forces of a foreign state.

NOTE: You may be asked to provide a copy of your military orders.

21. Request. Are you requesting a CLN 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.

22. Details of Service. Respond to items 22(a)-(8).

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 item 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 served in. ____________________

22(e) Ranks held. Include highest rank and dates (mm-dd-yyyy).

_____________

22(f)Responsibilities. List your responsibilities, duties, functions, and activities engaged in during your service.

22(g) Additional Information. Describe your decision to serve in the armed forces of the foreign state listed in item 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 item 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 item 22(a) voluntarily? Yes No

23(b) Describe any factors that may have influenced your decision to serve in the armed forces of the foreign state listed in item 22(a).

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 23(a).

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 (Items 25-28)

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

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). Attach additional pages if necessary.

26(a) Name of foreign country 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) Were you in a foreign country when you served? Yes No

26(c)(iii) If you were in the United States, 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 a foreign country? (mm-dd-yyyy)

26(d) Branch/Agency/Office served in.

26(e) Position(s) held, including dates (mm-dd-yyyy).

26(f) Responsibilities. List your responsibilities, duties, functions, and activities engaged in during your service.

26(g) Nationality. Were you a national of the foreign state listed in item 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? Yes No

If “Yes,” were you a national of the foreign country listed in item 26(a) at the time you took the oath of allegiance? Yes No

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 item 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 item 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 27(a)-(c) and explain your answers.

27(a) Did you accept, serve, or perform the duties of any position in the government of the foreign state listed in item 26(a) voluntarily? Yes No

27(b) Describe any factors that may have influenced your decision to accept, serve, or perform the duties of any position in the government of the foreign state listed in item 26(a).

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

CONTENT OF PART II

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.

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. Approval of a Certificate of Loss of Nationality of the United States (CLN) by the Department of State is 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, 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’s 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 to be deportable by a foreign country.

7. If the Department’s 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 affect my liability for 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 exempt me from United States income taxation. I understand that I must contact the United States Internal Revenue Service about any consequences related to United States taxation. Further, I understand that if my relinquishment of United States nationality is determined by the Secretary of the Department of Homeland Security to be motivated by tax avoidance purposes, I may be found excludable from the United States under Immigration and Nationality Act, as amended.

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 after the effective date of loss of nationality indicated on the CLN.

12. I choose ___ do not choose ____ (check one) to make a written statement explaining my reason(s) for requesting a Certificate of Loss of Nationality of the United States.

13. The serious and irrevocable nature of a final determination of loss of nationality has been explained to me by the (Vice) Consul at the [name of post] 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.

Name _________________(Typed)

Signature ______________

Signature date ______________ (mm-dd-yyyy)

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.

SEAL _______________________________

Consul of the United States of America

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 (specify below):

PART I-B PART I-C PART I-D PART I-E PART I-F

voluntarily and with the intent to relinquish my U.S. nationality.

Signature _______________

Signature Date ___________ (mm-dd-yyyy)

SEAL

Signature of Consular Officer __________ Date ___________(mm-dd-yyyy)

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 under Immigration and Nationality Act (INA) section 349(a)(5), please proceed to PART II-C below. If you wish to request a CLN based on one of the OTHER ACTS described in PART I under INA section 349(a)(1)-(4), as indicated in your responses to this Questionnaire, please proceed to PART II-D below and do not complete PART II-C below.

PART II-C OATH/AFFIRMATION OF RENUNCIATION OF NATIONALITY OF UNITED STATES

To be completed for a 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 under Immigration and Nationality Act (INA) section 349(a)(5).

[CURRENT FORM DS-4080 OATH/AFFIRMATION OF RENUNCIATION OF NATIONALITY OF UNITED STATES AS REVISED INSERTED HERE]

PART II-D ATTESTATION TO CORRECTNESS AND COMPLETENESS

This Questionnaire and attachments will become a 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 _______________________________________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)

SEAL

Signature of Consular Officer

Date (mm-dd-yyyy)

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, counterterrorism 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 U.S. Nationality of the United States if they do not provide the required 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/L CA/OCS/ACS, DEPARTMENT OF STATE, SA-17, 10th FLOOR, Washington, D.C. 20522.

16. Specify if the data gathered by this collection will be published.

The Department will not publish the data gathered by this collection.

17. If applicable, explain the reason(s) for seeking approval to not display the OMB expiration date.

The Department will display the OMB expiration date.

18. Explain any exceptions to the OMB certification statement below. The Department is not seeking exceptions to the certification statement.

B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS

This collection does not employ statistical methods.