Questionnaire - Loss of United States Nationality; Attestations

OMB 1405-0178

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.

The latest form for Questionnaire - Loss of United States Nationality; Attestations expires 2023-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form DS-4079 Questionnaire - Loss of United States Nationality; Attestations Form and Instruction
4079_Published.pdf Supplementary Document
PublishedFR_07-19-2023.pdf Supplementary Document
Legal Authorities.docx Supplementary Document
1405-0178 Supporting Statement.docx Supporting Statement A
Questionnaire - Loss of United States Nationality; Attestations Form and Instruction

All Historical Document Collections

202309-1405-004	Revision of a currently approved collection	2023-09-29
202002-1405-003 Approved with change	Revision of a currently approved collection	2020-02-25
201701-1405-014 Approved without change	Extension without change of a currently approved collection	2017-01-17
201310-1405-003 Approved with change	Extension without change of a currently approved collection	2013-10-24
201010-1405-001 Approved without change	Revision of a currently approved collection	2010-10-05
200708-1405-001 Approved without change	New collection (Request for a new OMB Control Number)	2007-08-07