Certificate: that the applicant performed the specified potentially expatriating act voluntarily and with the intent to relinquish U.S. nationality.
Name: full legal name of the applicant as appears on unexpired government-issued photo ID.
If performed in the United States: insert date of taking up residence in a foreign state under INA 351.
Potentially expatriating act: check ONLY one.
Signature: U.S. Diplomatic or Consular Officer.
Administrative review: see Page 2 for Information on Administrative Review.
| Question | Answer |
|---|---|
| Form Name | Form DS-4083 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 31 |
| Avg. time to fill out | 6 min |
| Edition | 11-2025 |
| Issuing agency | U.S. Department of State |
| Who signs | U.S. Diplomatic or Consular Officer |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | DS-4083, DS4083, DS 4083, Certificate of Loss of Nationality of the United States |
| Official source | Form DS-4083 (Rev 11-2025), U.S. Department of State |
Form Ds 4083 isn’t the one you’re looking for?