You should be aware that under United States law, a citizen may lose U.S. citizenship
if he/she voluntarily performs any of the acts specified above in questions 8(b)(iii)-11
with the intent of relinquishing United States citizenship. If you voluntarily performed
an act stated above with the intent to relinquish United States citizenship, you may
sign Part II of this statement before a Consular Officer at a U.S. Embassy or
Consulate. The U.S. Consulate or Embassy will prepare the forms necessary to
document your loss of U.S. citizenship.
STATEMENT OF VOLUNTARY RELINQUISHMENT OF U.S. CITIZENSHIP
, performed the act of expatriation indicated in Questions 8-19,
voluntarily and with the intent to relinquish my U.S. citizenship.
Signature Date (mm-dd-yyyy)
Signature of Consular Officer Date (mm-dd-yyyy)
Subscribed and Sworn
AUTHORITIES: The information on this form is requested under the authority of 8 U.S.C. 1104, 1481, 1483, 1488, and 1501, and 22 U.S.C.
PURPOSE: The principal purpose of gathering this information is to determine if the individual performed a potentially expatriating act as
defined in 8 U.S.C. 1481 voluntarily and with the intention of relinquishing U.S. nationality.
ROUTINE USES: The information solicited on this form may be made available to foreign government agencies to fulfill passport control
and immigration duties, to investigate or prosecute violations of law, or when a request for information is made pursuant to customary
international practice. In the event a finding of loss of nationality is made, the information solicited on this form may be made available to
other federal entities with law enforcement responsibilities relating to or affected by nationality, including but not limited to the U.S.
Citizenship and Immigration Service, the Internal Revenue Service, and the Federal Bureau of Investigation. The information provided also
may be released to federal, state or local agencies for law enforcement, counter-terrorism and homeland security purposes; to Congress
and courts within their sphere of jurisdiction; and to other federal agencies for certain personnel and records management matters. More
information on the Routine Uses for the system can be found in System of Records Notice, State-05, Overseas Citizens Services Records
and the Prefatory Statement of Routine Uses published in the Federal Register.
DISCLOSURE: Although furnishing the information is voluntary, applicants may not be eligible for a U.S. passport or for relinquishment or
renunciation of U.S. nationality if they do not provide the required information.
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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for
searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and
reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to:
CA/OCS/L, DEPARTMENT OF STATE, SA-17, 10th FLOOR, WASHINGTON, DC 20522-1707.
PRIVACY ACT STATEMENT
PAPERWORK REDUCTION ACT (PRA) STATEMENT
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