Ds 4079 Form – Fill Out and Use This PDF

U. S. Department of State

BUREAU OF CONSULAR AFFAIRS

REQUEST FOR DETERMINATION OF POSSIBLE LOSS OF

UNITED STATES NATIONALITY

The responses you provide to the questions on this form will be used in determining your nationality/nationalities and possible loss of U.S. nationality. A person claiming loss of U.S. nationality must establish by a preponderance of the evidence that he/she is/was a U.S. citizen who performed an expatriating act voluntarily and with intent to relinquish U.S. nationality before the Department of State can approve a Certificate of Loss of Nationality for that person. You may wish to consult an attorney before completing and submitting this form. Please read these instructions carefully before completing the form. The instructions contain important information about completing the form. Please direct any questions you may have about the form to our consular staff.

STEP 1: Read the instructions before completing and submitting this form. The instructions contain important information about completing the form.

STEP 2: Complete the form. Attach extra sheets of paper if needed to respond to any of the questions.

STEP 3: Make an appointment with the U.S. embassy or consulate online.

STEP 4: Assemble any supporting documents. Take the form and supporting documents with you to your

appointment at the U.S. embassy or consulate. NOTE: Do not sign the form until you are before a designated U.S. consular or diplomatic officer.

STEP 5: Upon completion of your interview with the consular or diplomatic officer, the consular or diplomatic officer will forward the completed form and supporting documentation along with his/her recommendation regarding your case to the Department for determination. If the Department does not request further information, it will send its decision to the U.S. embassy or consulate for delivery to you if approved (finding of loss) or to you directly in the case of a denial (no finding of loss).

ABOUT YOUR DOCUMENTS

You must submit ORIGINAL documents or copies certified by the custodian of the record. Generally, we will return your documents after we have seen them.

We cannot accept photocopies or notarized copies of documents.

DOCUMENTS WE MAY NEED TO SEE

When seeking a determination with respect to possible loss of U.S. nationality, the documentary evidence listed below should be presented. In certain instances, additional evidence may be required.

Unless otherwise provided, all documentation submitted must be originals or certified copies of the originals bearing the seal of the issuing vital records office, court, or other authority.

1.Evidence of your U.S. nationality and identity. This may consist of a U.S. passport, U.S. passport card, Consular Report of Birth Abroad, Naturalization Certificate, Certificate of Citizenship or timely filed U.S. birth certificate. For other forms of acceptable U.S. citizenship evidence, contact the U.S. embassy or consulate. A passport or government issued Photo ID must be presented as proof of identity.

2.Evidence of legal name change(s).You may present a court order, marriage certificate, divorce decree, or other evidence establishing a legal change of name.

3.Evidence of other nationality/nationalities. Foreign birth records, passports, Certificates of Naturalization or Citizenship.

HOW TO COMPLETE THIS FORM

Most of the items on the form are self-explanatory with the exception of the items discussed below. The numbers match the numbered items on the form.

1.Name: Enter your full legal name as it appears on your birth record. If your name has been legally changed by adoption, marriage, or certain other legal action amending your name from birth, the new name may be recorded on the form if supported by documentary evidence.

2.Date of Birth: Write the month before the date and year. (Example: 10-02-1990; [month]-[day]-[year])

3.Place of Birth: Enter the name of the city and country.

DS-4079 (Formerly FS-581)	Instruction Page 1 of 3
07-2019

HOW TO COMPLETE THIS FORM - (Continued)

Most of the items on the form are self-explanatory with the exception of the items discussed below. The numbers match the numbered items on the form.

4.(a) Enter the number of your most recent U.S. passport; if unknown or you have not been issued a U.S. passport, enter "unknown" or "not applicable" (n/a);

(b)Enter the place where your most recent U.S. passport was issued; if unknown, enter "unknown" or if you have not been issued a U.S. passport, enter "unknown" or "n/a";

(c)Enter the date that your most recent U.S. passport was issued. Write the month before the date and year. (Example: 10-02-2010; [month]-[day]-[year]). If unknown or you have not been issued a U.S. passport, enter "unknown" or "n/a."

5.If you were not born in the United States (or if you were but did not acquire U.S. nationality at birth), how did you acquire U.S. nationality? Check the applicable option. If you acquired U.S. nationality by naturalization, (a) list the name, city and state of the court or U.S. Citizenship and Immigration Services (or former Immigration and Naturalization Service) field office that issued your Certificate of Naturalization or Certificate of Citizenship. (b) Enter the date of naturalization. Write the month before the date and year (mm-dd-yyyy).

6.Enter the countries and dates of residence from birth to the present.

7.If you know, enter the approximate date that you first learned you are a U.S. national.

8.Other nationalities. If you answered "yes" to this question, respond to questions 8(a)-(c). If you are a national of more than one country other than the United States, please attach supplemental responses for each foreign country of which you are a national responding to the same questions in Question 8 (a)-(c).

9.Oath or Affirmation of Allegiance to a Foreign Country. If you have taken an oath or made an affirmation or other formal declaration of allegiance to more than one foreign country, please list other countries and dates of oath or affirmation on separate sheet and (a) indicate the nature of the oath, attaching the oath if available.

10.Service in the Armed Forces of a Foreign Country. If you answered "yes" to this question, respond to questions 10(a)-(g). If you served in the armed forces of more than one foreign country, please attach supplemental responses for each foreign country responding to the same questions in Question 10 (a)-(g).

11.Service in a Foreign Government. If you answered "yes" to this question, respond to questions 11(a)-(c). If you accepted, served in, or performed the duties of more than one office, post or employment with the government of a foreign country, and/or in more than one foreign government, please attach supplemental responses for each post and foreign country responding to the same questions in Question 11 (a)-(c).

12.Ties to a Foreign Country. For each country in which you have performed the act or acts indicated in Questions 8 through 11, list the country/countries and respond to questions 12 (a)-(e), attaching supplemental responses as necessary.

13.Ties to the United States. Respond to questions 13(a)-(g).

14.Passport(s) Used for Travel to and from the United States. Indicate whether you use a U.S. or foreign passport traveling either into or out of the United States.

15.Passport(s) Used for Travel to and from other Countries. Indicate whether you use a U.S. or foreign passport traveling either into or out of other countries. List name(s) of country/countries and passport used both to and from, attaching supplemental responses as necessary.

16.Oath of Renunciation of U.S. Nationality. If you answered that you have taken a formal oath of renunciation of U.S. nationality, indicate the date and place.

17.Details re: Performance of Act(s) in Question 8(b)(iii) - 11, and/or 16. For each act or acts performed as indicated in Questions 8 through 16, provide details of the circumstances under which you performed the act or acts, attaching supplemental responses and supporting documentation as necessary.

18.Voluntariness. If you answered "no" to this question with respect to any of the acts in Questions 8(b)(iii) - 11, and/or 16, (a) describe for each act or acts performed, how and/or why your performance of each act was involuntary, attaching supplemental responses and supporting documentation as necessary.

DS-4079 (Formerly FS-581)	Instruction Page 2 of 3
07-2019

HOW TO COMPLETE THIS FORM - (Continued)

19.Intent. With respect to any of the acts in Questions 8(b)(iii) - 11, and/or 16 that you performed, indicate your intent with respect to your U.S. nationality when performing each act or acts, attaching supplemental responses and supporting documentation as necessary.

20.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, in particular, to your intention or lack of intention to relinquish U.S. nationality, you may attach separate sheets with that information.

INFORMATION ABOUT MOTHER/FATHER/PARENT

5 & 11. Full Name: Enter Mother/Father/Parent's name as it appears on the passport and/or government issued identity document.

6 & 12. All Previous Legal Names: Enter all legal names ever used by father, including name at birth.

7 & 13. Sex: Check (X) box to indicate whether male or female.

8 & 14. Write the month before the day and year. (Example: 10-02-1990; [month]-[day]-[year])

9 &15. Place of Birth: Enter the name of the city, state/province (if applicable) and country.

10 & 16. Current Physical Address (Do not list a P.O. Box) (You may list an A.P.O. Address): Enter the address in the foreign country where the application is completed.

17.Enter Mailing Address

18 & 19. Citizenship: Please place an "X" in the "yes" box or the "no" box to indicate whether you were a U.S Citizen or Non-Citizen National when the child was born.

20.Enter yes or no if you and U.S. citizen parent of child were/was married to the child's other biological parent when the child was born.

21.List Date and Place of marriage and check current status of that marriage, adding date of death or divorce if applicable.

22 & 23. Marriage(s): Please list any other marriages as follows: Date of marriage; end date, if any; and manner ended, if applicable. If you have never been married, enter "none."

24 & 25. Time spent in the United States: List all dates you have been present in the United States.

26 & 27. Time spent abroad in U.S. Armed Forces, in other U.S. Government employment, with qualifying international organization, or as a dependent child of a person so employed: Official documentation of relevant periods of service from the appropriate governmental department or international organization must be presented. For names of qualifying organizations, consult the U.S. embassy or consulate.

28.Do not sign until you are appearing before the person administering the oath/affirmation.

29.Do not sign until you are appearing before the person administering the oath/affirmation.

30.The U.S. embassy or consulate official approving the issuance of the Consular Report of Birth Abroad will enter the serial number of the Consular Report of Birth Abroad and the date and place of issuance before signing this section.

DS-4079 (Formerly FS-581)	Instruction Page 3 of 3
07-2019

10. Have you served in the armed forces of a foreign country

Yes

No

(a) If yes, of what country?

(b) In which branch of the armed forces did you serve?

(c) Dates of Service (mm-dd-yyyy)

(d) What ranks did you hold?

(e) What was your highest rank?

(f) What responsibilities did you have and what functions and activities were you engaged in?

Yes

No

(g) Did you take an oath? If so, describe the oath.

11. Have you accepted, served in, or performed the duties of any office, post or employment with the

Yes

No

government of a foreign country?

(a) If yes, provide dates of service, country and the job title

(b) What were your duties and responsibilities for each of the foreign government jobs you held?

Yes

No

(c) Did you take an oath, affirmation, declaration or allegiance in connection with the job? If yes, describe the oath,

affirmation, or declaration of giance.

12. What ties do/did you have to the country where you performed the act or acts indicated in Questions 8-11? For example:

(a) Do/did you maintain a residence? If yes, explain.

Yes

No

No

(b) Do/did you own property? If yes, explain.

Yes

(c) Do/did you have family or social ties? If yes, explain.

Yes

No

DS-4079

(If more space is needed, use additional paper)

Page 2 of 5

12. (Continued)
(d) Do/did you vote? If yes, explain.	Yes	No

(e) What other ties do or did you have to the country where you performed the act or acts indicated in Questions 8-11?

13.What ties do you have with the United States? For example:

(a) Do you maintain a residence? If yes, explain.

Yes

No

(b) Do you own property? If yes, explain.		Yes		No
(c) Do you have family or social ties? If yes, explain.		Yes		No

14.	What passport(s) do you use to travel to and from the United States?
	From:		To:
15.	What passport do you use to travel to and from other countries?
16.	Have you renounced your U.S. nationality at a U.S. Consulate or Embassy? If yes, provide a date and place.							Yes		No
	Date:		Place:
DS-4079			(If more space is needed, use additional paper)						Page 3 of 5

17. Describe in detail the circumstances under which you performed the act or acts indicated in Questions 8(b)(iii) - 11, and/or 16.

19.What was your intent with respect to your U.S. nationality when you performed the act or acts indicated in questions 8(b)(iii)- 11 and/or 16?, Explain your answer.

20.Your answers on this form will become part of the official record in your case. Before signing this form, you are advised to consider consulting with an attorney, and to read over your answers 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 citizenship status, and in particular to your intention or lack of intention to relinquish U.S. citizenship, you may attach separate sheets with that information.

If your answer to each of the questions above is "No," please sign below before a Consular Officer at a U.S. Embassy or Consulate. If you answered "Yes", to one or more of questions 8(b)(iii)-11 and your action was completely VOLUNTARY, please continue with PART II.

Subscribed and Sworn

Signature

[SEAL]

Signature of Consular Officer

PART II

STATEMENT OF VOLUNTARY RELINQUISHMENT OF U.S. CITIZENSHIP

Subscribed and Sworn

I,						, performed the act of expatriation indicated in question(s)
(specify question number(s) 8(b)(iii)-11 and/or question 16)					, voluntarily and with the intent to relinquish my U.S. nationality.
		Signature						Date (mm-dd-yyyy)
	[SEAL]
		Signature of Consular Officer						Date (mm-dd-yyyy)
DS-4079		(If more space is needed, use additional paper)							Page 4 of 5

PRIVACY ACT STATEMENT

AUTHORITIES: The information on this form is requested under the authority of 8 U.S.C. 1104, 1481, 1483, 1488, and 1501, and 22 U.S.C. 212.

PURPOSE: The principal purpose of gathering this information is to determine if the individual performed a potentially expatriating act as defined in 8 U.S.C. 1481 voluntarily and with the intention of relinquishing U.S. nationality.

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. In the event a finding of loss of nationality is made, 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. More information on the Routine Uses for the system can be found in System of Records Notice, State-05, Overseas Citizens Services Records and the Prefatory Statement of Routine Uses published in the Federal Register.

DISCLOSURE: Although furnishing the information is voluntary, applicants may not be eligible for a U.S. passport or for a Certificate of Loss of U.S. Nationality 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 15 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, DEPARTMENT OF STATE, SA-17, 10th FLOOR,

DS-4079

Page 5 of 5