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Fillable Printable Form DS-4083

Fillable Printable Form DS-4083

Form DS-4083

Form DS-4083

CERTIFICATE OF LOSS OF NATIONALITY OF THE UNITED STATES
BUREAU OF CONSULAR AFFAIRS
SEE PAGE 2 FOR APPEAL PROCEDURES
U.S. Department of State
DS-4083 (Formerly FS-348)
08-2013
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).
Embassy/Consulateof the United States of America
at
ss:
I,
.
Name
hereby certify that, to the best of my knowledge and belief,
Name
was born at
Town or City
,
Province or County
State or Country
, on
Date
That: he/she resided/never resided in the United States
;
That: he/she resides at;
That: he/she acquired the nationality of the United States by virtue of
That: he/she acquired the nationality ofby virtue of
That: he/she
That: he/she thereby expatriated
self on
under the provisions of
Section
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
,
.
Signature
Title
[SEAL]
*Strikeout inapplicable item.
Page 1 of 2
That: said expatriating act was performed voluntarily with the intent to relinquish United States citizenship;
;
;
;
(mm-dd-yyyy)
(Dates*)
(The action causing expatriation should be set forth succinctly.)
(Date)
(mm-dd-yyyy)
of(The Nationality Act of 1940)* (The Immigration and Nationality Act
of 1952 as amended)
(Month)(Year)
DEPARTMENT USE ONLY
ADMINISTRATIVE REVIEW OF A FINDING OF LOSS OF NATIONALITY
The premise established by the administrative standard of evidence is applicable to
cases adjudicated previously. Persons who previously lost U.S. citizenship may wish to
have their cases reconsidered in light of this policy.
A person may initiate such a reconsideration by submitting a request to the nearest U.S.
consular office or by writing directly to:
Director
Office of Legal Affairs
Overseas Citizens Services
(CA/OCS/L)
U.S. Department of State
CA/OCS/L
SA-17, 10th Floor
Washington, DC 20522-1707
U.S. Department of State
CA/OCS/L
600 19th Street, NW
10th Floor
Washington, DC 20431
Each case will be reviewed on its own merits taking into consideration, for example,
statements made by the person at the time of the potentially expatriating act.
DS-4083
Page 2 of 2
For Additional Information, visit www.Travel.State.Gov and see the 'Legal
Considerations' section on U.S. Citizenship Laws and Policy.
or via express mail/courier service to
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