Information Collection

Questionnaire - Loss of United States Nationality; Attestations

IC 274993 under ICR 202504-1405-002 · OMB 1405-0178.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-4079 Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction
Form DS-4079 Loss of Citizenship Questionnaire - Loss of United States Nationality; Attestations	Form and Instruction
DS-4079 Loss of Citizenship MS Form and Instructions- Screenshots .pdf	Form and Instruction
DS-4079 Loss of Citizenship MS Form and Instructions- Screenshots .pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR 50.50 22 CFR 50.40

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-4079				Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records

Title: Loss of Citizenship

FR Citation: 88 FR 12128

Number of Respondents: 4,850

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	4,850	4,850
Annual IC Time Burden (Hours)	3,476	3,476
Annual IC Cost Burden (Dollars)	94,793	94,793

Documents for IC

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

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

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