Form Ds 4083 – Fill Out and Use This PDF

U.S. Department of State

BUREAU OF CONSULAR AFFAIRS

CERTIFICATE OF LOSS OF NATIONALITY OF THE UNITED STATES

This form is prescribed by the Secretary of State pursuant to Section 501 of the Act of

October 14, 1940 (54 Stat. 1171) and Section 358 of the Act of June 27, 1952 (66 Stat. 272).

(Name)

was born at

,

(Town or City)

(Province or County)

, on

(State or Country)

(Date (mm-dd-yyyy))

That: he/she (never resided in the United States (dates*));

;

That: he/she resides at

;

That: he/she acquired the nationality of the United States by virtue of

;

;

That: he/she acquired the nationality of

by virtue of

That: he/she

(The action causing expatriation should be set forth succinctly.)

That: said expatriating act was performed voluntarily with the intent to relinquish United States citizenship;

	That:	he/she thereby expatriated			self on (Date):		under the provisions of
Section			of (The Nationality Act of 1940)* (The Immigration and Nationality Act of 1952 as
			amended)

That the evidence of such action consists of the following:

;

That attached to and made a part of this certificate are the following documents or copies thereof:

In testimony whereof, I have hereunto subscribed by name and affixed my office seal this

day of		,				.
	[SEAL]
							(Signature)
*Strikeout inapplicable item.							(Title)
DS-4083 (Formerly FS-348)							Page 1 of 2
01-2007				SEE PAGE 2 FOR APPEAL PROCEDURES

APPEAL PROCEDURES

Any holding of loss of United States nationality may be appealed to the Board of Appellate Review or other designated office of the Department of State within one year or thereafter. The regulations governing appeals are set forth at Title 22 of the Code of Federal Regulations, Part 7. Notice of appeal should be addressed to the Board of Appellate Review, or other designated office and may be submitted through an American Embassy or Consulate or through an authorized attorney in the United States or directly to the Director, Office of Policy Review and Inter-Agency Liaison, Overseas Citizens Services, Bureau of Consular Affairs, SA-29, 4th Floor, U.S. Department of State, Washington, D.C. 20520.

You are advised to consult an attorney in the preparation and presentation of your appeal.

The appeal must be in writing and it must state with particularity the reason why it is being made. It may be accompanied by a legal brief. Any statement of facts or circumstances not mentioned when the case was previously considered should be sworn to before an official authorized to take oaths and should be supported by the best evidence obtainable.

For additional information about appeal procedures and to obtain copies of the relevant provisions of the Code of Federal Regulations, consult the nearest American Embassy or Consulate, or write to the Board of Appellate Review, Department of State, Washington, D.C. 20520.

For Additional Information See

http://www.travel.state.gov/law/citizenship/citizenship_778.html

DS-4083

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