Questionnaire - Loss of United States Nationality; Attestations

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DS-4079 Loss of Citizenship	Form and Instruction	New	Available
Form DS-4079 Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	New	Repair queued
Form DS-4079 Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	Unchanged	Available
Form DS-4079 Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	Unchanged	Repair queued
Justification for using MS Forms for DS 4079 PART I FINAL.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-22	Available
Justification for using MS Forms for DS 4079 PART I FINAL.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-04-22	Missing upstream
Non-Substantive Change 1405-0178 DS-4079.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-29	Available
Non-Substantive Change 1405-0178 DS-4079.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-29	Repair queued
4079_Published.pdf	Supplementary Document	Uploaded 2023-09-29	Available
4079_Published.pdf	Supplementary Document	Uploaded 2023-09-29	Repair queued
PublishedFR_07-19-2023.pdf	Supplementary Document	Uploaded 2023-09-28	Available
PublishedFR_07-19-2023.pdf	Supplementary Document	Uploaded 2023-09-28	Repair queued
Legal Authorities.docx	Supplementary Document	Uploaded 2023-09-28	Available
Legal Authorities.docx	Supplementary Document	Uploaded 2023-09-28	Repair queued
1405-0178 Supporting Statement - CLEAN 10.24.2024.docx	Supporting Statement A	Uploaded 2024-10-24	Available
1405-0178 Supporting Statement - CLEAN 10.24.2024.docx	Supporting Statement A	Uploaded 2024-10-24	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
274993	Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	New	Loss of Citizenship
274993	Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	New
181472	Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	Unchanged	Questionnaire - Loss of United States Nationality; Attestations
181472	Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction	Unchanged

ICR Details

OMB Control No: 1405-0178	ICR Reference No: 202504-1405-002
Status: Active	Previous ICR Reference No: 202503-1405-007
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: Questionnaire - Loss of United States Nationality; Attestations
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/27/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/22/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2027	10/31/2027	10/31/2027
Responses	9,700	0	4,850
Time Burden (Hours)	6,952	0	3,476
Cost Burden (Dollars)	189,586	0	94,793

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

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 46359	07/19/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 67419	09/29/2023
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Questionnaire - Loss of United States Nationality; Attestations	DS-4079	Loss of Citizenship
Questionnaire - Loss of United States Nationality; Attestations	DS-4079	Questionnaire - Loss of United States Nationality; Attestations

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	9,700	4,850	0	0	4,850	0
Annual Time Burden (Hours)	6,952	3,476	0	0	3,476	0
Annual Cost Burden (Dollars)	189,586	94,793	0	0	94,793	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: See Supporting Statement.

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Annual Cost to Federal Government: $306,762

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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

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

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

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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

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

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

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

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

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

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

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

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

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

(v) Nature and extent of confidentiality; and

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

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

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

(j) It makes appropriate use of information technology.

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

Certification Date: 04/22/2025

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