Form DS-4083 at a glance
What it is: The U.S. Department of State Certificate of Loss of Nationality of the United States, as prescribed by Section 358 of the Act of June 27, 1952 (66 Stat. 272).
Who signs: Write the Signature of U.S. Diplomatic or Consular Officer by the [SEAL].
A filled-in Form DS-4083 example: a naturalization in Canada
How to fill out Form DS-4083, box by box
United States Embassy/Consulate, City and Country
Under United States Embassy/Consulate, write the City and the Country.
Diplomatic or Consular Officer Name and Title, and the Name of the APPLICANT
Write the Diplomatic or Consular Officer Name and Title; the officer hereby certifies that, to the best of the officer's knowledge and belief, and writes the Name (Full legal name of APPLICANT as appears on unexpired government-issued photo ID).
Born at, and Date of Birth
Under was born at, write the Town or City and the County, then the State/Province and the Country.
Write the Date of Birth as mm-dd-yyyy.
Where the APPLICANT resides
Write the full address where the APPLICANT resides; no P.O. Box.
Nationality of the United States and of a foreign country
Check at birth or after birth (naturalization) for the nationality of the United States that the APPLICANT acquired.
Write the Country of Foreign Nationality the APPLICANT acquired, and check at birth or after birth (naturalization).
The potentially expatriating act, where it was performed and the date of relinquishment
Check ONLY one statute for the potentially expatriating act: INA section 349(a)(1), 349(a)(2), 349(a)(3)(A) or (B), 349(a)(4)(A) or (B), 349(a)(5), or Other, and specify the section of law.
Write the Date of Performance of Specified Act as mm-dd-yyyy and the Country Where Performed.
Write the date the APPLICANT relinquished U.S. nationality as mm-dd-yyyy; if performed in the United States, insert the date of taking up residence in a foreign state under INA 351.
The APPLICANT performed the specified potentially expatriating act voluntarily and with the intent to relinquish U.S. nationality.
Attached documents and the Signature of U.S. Diplomatic or Consular Officer
List the documents or copies thereof that are attached to and made a part of this Certificate.
In testimony whereof, I have hereunto subscribed by name and affixed my office seal this day of: write the day, the Month and the Year.
Write the Signature of U.S. Diplomatic or Consular Officer by the [SEAL].
More rules for Form DS-4083
You may request administrative review of a previous issuance of a Certificate of Loss of Nationality of the United States in your name and/or a denial of a request for the issuance of such a Certificate by submitting a request to the nearest U.S. embassy or consulate or by writing directly to Loss of Nationality - Administrative Reviews U.S. Department of State, CA/OCS/ACS SA-17, 10th Floor Washington, D.C.
Sources
[1] Form DS-4083 (11-2025), Certificate of Loss of Nationality of the United States, U.S. Department of State (the Official source link on this page).