Subscribed and sworn/affirmed to before me this
U. S. Department of State
BUREAU OF CONSULAR AFFAIRS
OATH/AFFIRMATION OF RENUNCIATION OF
NATIONALITY OF UNITED STATES
at
(Embassy/Consulate)
ss:
I,
Name (Print Full Name)
a national of the United States,
solemnly swear/affirm that I was born at
,
(Province or County)
,
(State or Country)
, on
Date (mm-dd-yyyy)
That I formerly resided in the United States at:
(Street Address)
(City, State and ZIP Code)
That I am a national of the United States by virtue of:
Birth in United States or Abroad to U.S. Parent(s)
Naturalization Date of Naturalization
(If naturalized, give the name and place of the court in the United States before which naturalization was
granted.)
(Name of Court)
(Street Address)
(City, State and ZIP Code)
I desire and hereby make a formal renunciation of my U.S. nationality, as provided by section 349(a)(5) of the
Immigration and Nationality Act of 1952, as amended, and pursuant thereto, I hereby absolutely and entirely
renounce my United States nationality together with all rights and privileges and all duties and allegiance and
fidelity thereunto pertaining. I make this renunciation intentionally, voluntarily, and of my own free will, free of any
duress or undue influence.
(Signature)
day of
,
,
at the
(Embassy/Consulate) (Place)
(Signature of Officer)
(Typed Name of Officer)
(Title of Officer)
DS-4080
05-2017
Date (mm-dd-yyyy)
SEAL
,
(Country)
(City or Town)
A renunciation of United States nationality/citizenship is effective only upon approval by the U.S. Department
of State but, when approved, the loss of nationality/citizenship occurs as of the date the above Oath/Affirmation
was taken.
Note:
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