Information Collection

Request for Determination of Possible Loss of United States Citizenship

IC 181472 under ICR 201010-1405-001 · OMB 1405-0178.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0178 can be found here:

Documents and Forms

Document Name Document Type
Form DS-4079 Request for Determination of Possible Loss of United States Citizenship Form and Instruction
DS-4079 Questionnaire: Information for Determining Possible Loss DS-4079 .pdf Form and Instruction
DS-4079 Request for Determination of Possible Loss of United Sta DS-4079 (10-2010).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Determination of Possible Loss of United States Citizenship	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 22 CFR 50.50 22 CFR 50.40

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DS-4079	Request for Determination of Possible Loss of United States Citizenship (2010)	DS-4079 (10-2010).pdf		Yes	No	Fillable Printable
Form and Instruction	DS-4079	Questionnaire: Information for Determining Possible Loss of U.S. Citizenship	DS-4079 .pdf		Yes	No	Fillable Printable

Line of Business: International Affairs and Commerce

Subfunction: Foreign Affairs

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,132	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,132	-1,166	2,298
Annual IC Time Burden (Hours)	283	-292	575
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.