Personal Information
Title (Mr. or Ms.)
Last Name
First and Middle Name
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PART I-A BACKGROUND INFORMATION
1. Name(s)/Aliases (Last, First, MI)
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Date of Birth
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3.
Date
of
Birth
(mm-dd-yyyy)
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City of Birth
State of Birth
Country of Birth
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4.
Place
of
Birth
(city,
state/province,
and
country)
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Aliases
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1. Name(s)/Aliases (Last, First, MI)
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Email Address
Telephone Number
Current Residential Address
(street and Number)
Current Residential Address (Postal Code and Country)
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2.
Mailing
Address,
Email
Address,
and
Phone
Number.
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How did you acquire U.S. citizenship?
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5. How did you acquire
U.S. nationality?
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Can you submit your last issued U.S.
passport?
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No corresponding request
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If the applicant has been issued this document but no longer has
it a statement is required, this is why the question is asked.
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Last U.S.
Passport Number
Last U.S. Passport Issuance Date
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6. Documentation of U.S.
Nationality (Check all that apply)
U.S.
Passport
6(a)
Last U.S. Passport Number: 6(b) Issued at (Place): 6(c) Issued
on (Date)(mm-dd-yyyy):
U.S.
Birth Certificate
Consular
Report of Birth Abroad Certificate of Naturalization Certificate
of Citizenship
Other (please specify):
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Can you submit your Consular Report of
Birth Abroad (CRBA)?
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No corresponding request
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If the applicant has been issued this document but no longer has
it a statement is required, this is why the question is asked.
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Can you submit your U.S. issued birth
certificate?
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No corresponding request
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If the applicant has been issued this document but no longer has
it a statement is required, this is why the question is asked.
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Can you submit your U.S. Certificate of
Naturalization?
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No corresponding request
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If the applicant has been issued this document but no longer has
it a statement is required, this is why the question is asked.
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Can you submit your U.S. Certificate of
Citizenship?
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No corresponding request
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If the applicant has been issued this document but no longer has
it a statement is required, this is why the question is asked.
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Are you a naturalized U.S. citizen?
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5. How did you acquire
U.S. nationality?
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Do you reside in
the United States?
Do you currently maintain a residence in the United
States?
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7. Ties to the United
States
7(a)
Residence
7(a)(i)
Do you reside in the United States? Yes No
If
"Yes," list your address.
7(a)(ii)
Do you currently maintain a residence in the United
States? Yes No
If "Yes,"
provide the address(es) and dates of stay, if any.
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Do you receive
any benefit or service or exercise any right or privilege that
requires U.S. citizenship and/or proof of residence in the
United States?
U.S. passport (unexpired) y/n
Medical/Professional Licenses
y/n
Voting in U.S. elections y/n
Medicare y/n
Disability benefits y/n
Retirement benefits y/n
U.S. state driver’s
license y/n
Documenting your children as
U.S. citizens y/n
U.S. immigration benefits y/n
Any other right or benefit
that requires U.S. citizenship and/or proof of residence in the
United States y/n
If Yes, specify the right or benefit
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7(b)
Rights/Benefits. Do you receive any benefit or service or
exercise any right or privilege that requires U.S. citizenship
and/or proof of residence in the United States? Y/N If Yes,
list below:
U.S.
passport (unexpired) y/n
Medical/Professional
Licenses y/n
Voting
in U.S. elections y/n
Medicare
y/n
Disability
benefits y/n
Retirement
benefits y/n
U.S.
state driver’s license y/n
Documenting
your children as U.S. citizens y/n
U.S.
immigration benefits y/n
7(b)
cont’d
Any
other right or benefit that requires U.S. citizenship and/or
proof of residence in the United States y/n If Y, specify below
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For which
country do you hold another nationality? Switzerland or other
When did you acquire your
foreign citizenship?
How did you obtain your foreign citizenship?
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8. Other Nationalities
8(a)
Are you a national or citizen of any other country other than the
United States?
If "Yes,"
list the country/countries and indicate how you acquired that
nationality.
Country
of Other Nationality
Manner
of Acquisition (How you acquired)
Date
of Acquisition
(mm-dd-yyyy)
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Items 37 and 38 on the MS Form have been reworded. Is this
permissible?
(If they need to conform to the
DS-4079 content,
Item 37 on the MS Form should read
“When did you acquire the nationality of the foreign
state?” and
Item 38 should read “How did you acquire the nationality
of the foreign state?”)
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Do you hold a 2nd foreign
nationality? y/n
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PART I-A BACKGROUND
INFORMATION
8.
Other Nationalities
8(a) Are you a national
or citizen of any other country other than the United States? If
"Yes," list the country/countries
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Are you
requesting a Certificate of Loss of Nationality of the United
States based on taking an oath of renunciation of U.S.
nationality before a U.S. diplomatic or consular officer and are
you choosing to take the oath of renunciation voluntarily?
Yes – INA 349(a)(5)
No, I request a CLN based on
naturalizing in a foreign state. INA 349(a)(1)
No, I request a CLN based on taking
an oath of allegiance to a foreign state. INA 349(a)(2)
No, I request a CLN based on
service in the armed forces of a foreign state. INA 349(a)(3)
No, I request a CLN based on accepting, having served in, or
serving in, or performing the duties of any office, post, or
employment with the government of a foreign state. INA 349(a)(4)
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PART I-B - OATH OF
RENUNCIATION
9.
Request.
Are
you
requesting
a
Certificate
of
Loss
of
Nationality
of
the
United
States based on taking an oath of renunciation of U.S.
nationality before a U.S. diplomatic or consular officer in
a
foreign country?
11(a)
Are you choosing to take the oath of renunciation voluntarily?
PART
I-C NATURALIZATION IN A FOREIGN STATE
13.
Request.
Are
you
requesting
a
CLN
based
on
naturalizing
in
a
foreign
state?
PART
I-D - OATH OF ALLEGIANCE TO A FOREIGN STATE
17.
Request.
Are
you
requesting
a
Certificate
of
Loss
of
Nationality
of
the
United
States
based on taking an oath of allegiance to a foreign state?
PART
I-E - SERVICE IN THE ARMED FORCES OF A FOREIGN STATE
21.
Request.
Are
you
requesting
a
Certificate
of
Loss
of
Nationality
of
the
United
States
based on service
in
the
armed
forces
of
a
foreign
state?
PART
I-F - EMPLOYMENT IN THE GOVERNMENT OF A FOREIGN STATE
25.
Request.
Are
you
requesting
a
CLN
based
on
employment
with
the
government
of
a
foreign
state?
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Describe any
factors that may have influenced your decision to take the oath
of renunciation
Describe whether you feel/felt
pressured by any person and/or circumstance to take the oath of
renunciation.
What is your intent with respect to your U.S. nationality
in taking the oath of renunciation?
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PART I-B - OATH OF
RENUNCIATION
11(b)
Describe
any
factors
that
may
have
influenced
your
decision
to
take
the
oath
of
renunciation.
11(c)
Describe
whether
you
feel/felt
pressured
by
any
person
and/or
circumstance
to
take
the
oath
of
renunciation.
12.
Intent.
What
is
your
intent
with
respect
to
your
U.S.
nationality
in
taking
the
oath
of
renunciation?
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Please state
your preference when taking the Oath of Renunciation swear or
affirm
Do you wish to make an optional written statement
explaining your reasons?
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No corresponding item on
the DS-4079
No corresponding item
on the DS-4079, but at the bottom of each page is an instruction,
“(If
more
space
is
needed,
use
additional
paper)”
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The applicant is asked to swear or affirm in Part II-A, this is
asked to aid post in pre-filling ahead of the second interview.
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