U. S. Department of State
Bureau of Consular Affairs
I,
,
understand that:
I have the right to renounce/relinquish my United States nationality.
1.
I am exercising my right of renunciation/relinquishment freely and voluntarily without force, compulsion or
3.
undue influence placed upon me by any person.
4. Upon renouncing/relinquishing my U.S. nationality, I will become an alien with respect to the United States,
subject to all laws and procedures of the United States regarding entry and control of aliens.
5.
If I do not possess the nationality/citizenship of any country other than the United States, upon
my renunciation/relinquishment I will become a stateless person and may face extreme difficulties traveling
internationally and entering most countries and maintaining a place to reside.
6. If I am found to be deportable by a foreign country, my renunciation/relinquishment may not prevent my
involuntary return to the United States.
My renunciation/relinquishment may not affect my military or selective service status, if any. I understand that
any problems in this area must be resolved with the appropriate agencies.
7.
My renunciation/relinquishment may not affect my liability, if any, to prosecution for any crimes which I may
have committed or may commit in the future which violate United States law.
8.
My renunciation/relinquishment may not exempt me from United States income taxation. With regard to
10.
United States taxation consequences, I understand that I must contact the United States
nationality is determined by the United States Attorney General to be motivated by tax
avoidance purposes, I will be found excludable from the United States under Immigration and
Nationality Act, as amended.
12.
the (Vice) consul
at the American
Embassy/Consulate General at
. I fully understand its
consequences.
Name (Typed)
choose to make a separate written explanation of my reasons for renouncing/relinquishing
that I have:
do
do not
my United States nationality.
I: swear had read to meread
The extremely serious and irrevocable nature of the act of renunciation/relinquishment has been explained to me by
I:
this statement in the
Internal Revenue Service. Further, I understand that if my renunciation of United States
DS-4081
05-2017
STATEMENT OF UNDERSTANDING CONCERNING THE CONSEQUENCES AND
RAMIFICATIONS OF RENUNCIATION OR RELINQUISHMENT OF U.S. NATIONALITY
I have the intention of relinquishing my United States nationality.
2.
My renunciation/relinquishment may not affect my liability for extradition to the United States.
9.
Upon renouncing/relinquishing my U.S. nationality, I will no longer be able to transmit U.S. nationality to my
children born subsequent to this act.
language and fully understand its contents.
11.
affirm
Page 1 of 2
Signature
click to sign
signature
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CONSULAR OFFICER'S ATTESTATION
appeared personally and:
had read to him/herread
this statement after my explanation of its meaning and the consequences of renunciation/relinquishment of United States
nationality and signed this statement:
under oath by affirmation before me this
day of
,
Consul of the United States of America
(Month) (Year)
(Day)
SEAL
Page 2 of 2DS-4081
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