U. S. Department of State
BUREAU OF CONSULAR AFFAIRS
WITNESSES' ATTESTATION RENUNCIATION/RELINQUISHMENT OF CITIZENSHIP
The undersigned persons certify that they witnessed the personal appearance of
before the consular officer
(Name)
(Name)
, who explained the seriousness and
consequences of renunciation/relinquishment of United States citizenship as outlined in Form DS-4081
Statement of Understanding Concerning the Consequences and Ramifications of Renunciation of U.S.
Citizenship, and explained the meaning of the Statement of Understanding, after which this Statement
and the Oath of Renunciation of the Nationality of the United States (DS 4080) were signed by the
Renunciant:
under oath by affirmation
before the named consular officer and undersigned witnesses this
day of
(Month) (Year)
(Day)
Full Name
Complete Address
Witness
Full Name
Complete Address
Witness
DS-4082
06-2007
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