Justification for MS Form Use

JUSTIFICATION FOR USING MS FORMS TO COLLECT INFORMATION REQUESTED ON THE DS-4079 PART I

In addition to seeking authorization for posts currently using MS Forms (U.S. Embassy Bern, Mission Australia), the Department seeks permission to use the MS Form collection vehicle at all posts within the parameters listed in this justification.

On October 24, 2024, OMB/OIRA approved the form DS-4079 Questionnaire- Loss of United States Nationality; Attestations, OMB Control Number: 1405-0178. A person who requests a Certificate of Loss of Nationality of the United States must complete the DS-4079. An applicant completes but does not sign PART I of the form and submits it electronically as part of the first of two required interviews. An electronic pdf version of the DS-4079 is available on eforms.state.gov, allowing applicants to type their information into PART I of the form for submission to the U.S. embassy or consulate (post).  PART II of the DS-4079 must be completed and signed by the applicant in person before a U.S. diplomatic or consular officer at the second required interview.

An alternative data input method for applicants utilizing the Microsoft Forms application has been used by some posts and provides the same functionality as the pdf file. Specifically, to streamline and expedite the intake process for applicants and posts, several posts have created/shared a Microsoft Form (MS Form) that applicants for Certificate of Loss of Nationality (CLN) services are directed to fill out on post’s website. There is a disclaimer on the page and on the Microsoft form itself stating “the information you provide will be used to generate your draft DS-4079 – Questionnaire – Loss of U.S. Nationality form. If you do not wish to complete this form electronically, please email Post@state.gov for alternate instructions.”

The MS Form requires that the applicant provide the same information needed to prepare PART I of the OMB approved Department Form DS-4079 with a few additional requests related to whether the person can submit certain documentation of U.S. citizenship and whether the person wishes to swear or affirm the oath of renunciation and/or submit an additional statement explaining why the person is choosing to take the oath of renunciation. (See below list of questions with corresponding cite to the DS-4079 PART I if applicable.)  After an applicant completes the MS Form, it is routed through Power Automate to a SharePoint and Excel spreadsheet for post staff review and population of the associated areas of the DS-4079 PART I-A and other applicable sections (most often, PART I-B, questions related to taking the oath of renunciation before a U.S. diplomatic or consular officer abroad under INA 349(a)(5)) in Microsoft Word via mail merge.  Post staff check for completeness of answers and send the electronic first interview (EFI) (almost all posts using the MS form thus far are EFI approved) confirmation and mark the case as ready for second interview/scheduling. The form DS-4079 would then be printed by the consular officer and reviewed by the applicant for accuracy during the applicant’s in-person second interview at which PART II could be completed and signed.

MS FORM CONTENT WITH CORRESPONDING CITE TO DS-4079 PART I CONTENT IF APPLICABLE

MS Form Item Number and Request.	Corresponding DS-4079 PART I Item Number and Request	Comments
Personal Information Title (Mr. or Ms.) Last Name First and Middle Name	PART I-A BACKGROUND INFORMATION 1. Name(s)/Aliases (Last, First, MI)
Date of Birth	3. Date of Birth (mm-dd-yyyy)
City of Birth State of Birth Country of Birth	4. Place of Birth (city, state/province, and country)
Aliases	1. Name(s)/Aliases (Last, First, MI)
Email Address Telephone Number Current Residential Address (street and Number) Current Residential Address (Postal Code and Country)	2. Mailing Address, Email Address, and Phone Number.
How did you acquire U.S. citizenship?	5. How did you acquire U.S. nationality?
Can you submit your last issued U.S. passport?	No corresponding request	If the applicant has been issued this document but no longer has it a statement is required, this is why the question is asked.
Last U.S. Passport Number Last U.S. Passport Issuance Date	6. Documentation of U.S. Nationality (Check all that apply) U.S. Passport 6(a) Last U.S. Passport Number: 6(b) Issued at (Place): 6(c) Issued on (Date)(mm-dd-yyyy): U.S. Birth Certificate Consular Report of Birth Abroad Certificate of Naturalization Certificate of Citizenship Other (please specify):
Can you submit your Consular Report of Birth Abroad (CRBA)?	No corresponding request	If the applicant has been issued this document but no longer has it a statement is required, this is why the question is asked.
Can you submit your U.S. issued birth certificate?	No corresponding request	If the applicant has been issued this document but no longer has it a statement is required, this is why the question is asked.
Can you submit your U.S. Certificate of Naturalization?	No corresponding request	If the applicant has been issued this document but no longer has it a statement is required, this is why the question is asked.
Can you submit your U.S. Certificate of Citizenship?	No corresponding request	If the applicant has been issued this document but no longer has it a statement is required, this is why the question is asked.
Are you a naturalized U.S. citizen?	5. How did you acquire U.S. nationality?
Do you reside in the United States? Do you currently maintain a residence in the United States?	7. Ties to the United States 7(a) Residence 7(a)(i) Do you reside in the United States? Yes No If "Yes," list your address. 7(a)(ii) Do you currently maintain a residence in the United States? Yes No If "Yes," provide the address(es) and dates of stay, if any.
Do you receive any benefit or service or exercise any right or privilege that requires U.S. citizenship and/or proof of residence in the United States? U.S. passport (unexpired) y/n Medical/Professional Licenses y/n Voting in U.S. elections y/n Medicare y/n Disability benefits y/n Retirement benefits y/n U.S. state driver’s license y/n Documenting your children as U.S. citizens y/n U.S. immigration benefits y/n Any other right or benefit that requires U.S. citizenship and/or proof of residence in the United States y/n If Yes, specify the right or benefit	7(b) Rights/Benefits. Do you receive any benefit or service or exercise any right or privilege that requires U.S. citizenship and/or proof of residence in the United States? Y/N If Yes, list below: U.S. passport (unexpired) y/n Medical/Professional Licenses y/n Voting in U.S. elections y/n Medicare y/n Disability benefits y/n Retirement benefits y/n U.S. state driver’s license y/n Documenting your children as U.S. citizens y/n U.S. immigration benefits y/n 7(b) cont’d Any other right or benefit that requires U.S. citizenship and/or proof of residence in the United States y/n If Y, specify below
For which country do you hold another nationality? Switzerland or other When did you acquire your foreign citizenship? How did you obtain your foreign citizenship?	8. Other Nationalities 8(a) Are you a national or citizen of any other country other than the United States? If "Yes," list the country/countries and indicate how you acquired that nationality. Country of Other Nationality Manner of Acquisition (How you acquired) Date of Acquisition (mm-dd-yyyy)	Items 37 and 38 on the MS Form have been reworded. Is this permissible? (If they need to conform to the DS-4079 content, Item 37 on the MS Form should read “When did you acquire the nationality of the foreign state?” and Item 38 should read “How did you acquire the nationality of the foreign state?”)
Do you hold a 2nd foreign nationality? y/n	PART I-A BACKGROUND INFORMATION 8. Other Nationalities 8(a) Are you a national or citizen of any other country other than the United States? If "Yes," list the country/countries
Are you requesting a Certificate of Loss of Nationality of the United States based on taking an oath of renunciation of U.S. nationality before a U.S. diplomatic or consular officer and are you choosing to take the oath of renunciation voluntarily? Yes – INA 349(a)(5) No, I request a CLN based on naturalizing in a foreign state. INA 349(a)(1) No, I request a CLN based on taking an oath of allegiance to a foreign state. INA 349(a)(2) No, I request a CLN based on service in the armed forces of a foreign state. INA 349(a)(3) No, I request a CLN based on accepting, having served in, or serving in, or performing the duties of any office, post, or employment with the government of a foreign state. INA 349(a)(4)	PART I-B - OATH OF RENUNCIATION 9. Request. Are you requesting a Certificate of Loss of Nationality of the United States based on taking an oath of renunciation of U.S. nationality before a U.S. diplomatic or consular officer in a foreign country? 11(a) Are you choosing to take the oath of renunciation voluntarily? PART I-C NATURALIZATION IN A FOREIGN STATE 13. Request. Are you requesting a CLN based on naturalizing in a foreign state? PART I-D - OATH OF ALLEGIANCE TO A FOREIGN STATE 17. Request. Are you requesting a Certificate of Loss of Nationality of the United States based on taking an oath of allegiance to a foreign state? PART I-E - SERVICE IN THE ARMED FORCES OF A FOREIGN STATE 21. Request. Are you requesting a Certificate of Loss of Nationality of the United States based on service in the armed forces of a foreign state? PART I-F - EMPLOYMENT IN THE GOVERNMENT OF A FOREIGN STATE 25. Request. Are you requesting a CLN based on employment with the government of a foreign state?
Describe any factors that may have influenced your decision to take the oath of renunciation Describe whether you feel/felt pressured by any person and/or circumstance to take the oath of renunciation. What is your intent with respect to your U.S. nationality in taking the oath of renunciation?	PART I-B - OATH OF RENUNCIATION 11(b) Describe any factors that may have influenced your decision to take the oath of renunciation. 11(c) Describe whether you feel/felt pressured by any person and/or circumstance to take the oath of renunciation. 12. Intent. What is your intent with respect to your U.S. nationality in taking the oath of renunciation?
Please state your preference when taking the Oath of Renunciation swear or affirm Do you wish to make an optional written statement explaining your reasons?	No corresponding item on the DS-4079 No corresponding item on the DS-4079, but at the bottom of each page is an instruction, “(If more space is needed, use additional paper)”	The applicant is asked to swear or affirm in Part II-A, this is asked to aid post in pre-filling ahead of the second interview.