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REQUEST FOR DETERMINATION OF POSSIBLE LOSS OF …

U. S. Department of StateBUREAU OF CONSULAR AFFAIRSREQUEST FOR DETERMINATION OF POSSIBLE LOSS OF UNITED STATES NATIONALITYThe responses you provide to the questions on this form will be used in determining your nationality/nationalities and POSSIBLE loss of nationality. A person claiming loss of nationality must establish by a preponderance of the evidence that he/she is/was a citizen who performed an expatriating act voluntarily and with intent to relinquish 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.

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. 19. 20. DS-4079 (Formerly FS-581) 07-2019

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