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That said expatriating act was performed voluntarily with the intent to relinquish United States citizenship That he/she thereby expatriated self on Date under the provisions of of The Nationality Act of 1940 The Immigration and Nationality Act of 1952 as amended Section That the evidence of such action consists of the following That attached to and made a part of this certificate are the following documents or copies thereof In testimony whereof I have hereunto subscribed by name and affixed my office seal this day of SEAL Signature Title Strikeout inapplicable item. DS-4083 Formerly FS-348 01-2007 SEE PAGE 2 FOR APPEAL PROCEDURES Page 1 of 2 APPEAL PROCEDURES Any holding of loss of United States nationality may be appealed to the Board of Appellate Review or other designated office of the Department of State within one year or thereafter. U*S* Department of State BUREAU OF CONSULAR AFFAIRS CERTIFICATE OF LOSS OF NATIONALITY OF THE UNITED STATES This form is prescribed by the Secretary of State pursuant to Section 501 of the Act of October 14 1940 54 Stat. 1171 and Section 358 of the Act of June 27 1952 66 Stat. 272. DEPARTMENT USE ONLY of the United States of America Consulate at ss I. Name hereby certify that to the best of my knowledge and belief was born at Town or City Province or County on State or Country Date mm-dd-yyyy That he/she never resided in the United States dates That he/she resides at That he/she acquired the nationality of the United States by virtue of by virtue of That he/she The action causing expatriation should be set forth succinctly. The regulations governing appeals are set forth at Title 22 of the Code of Federal Regulations Part 7. Notice of appeal should be addressed to the Board of Appellate Review or other designated office and may be submitted through an American Embassy or Consulate or through an authorized attorney in the United States or directly to the Director Office of Policy Review and Inter-Agency Liaison Overseas Citizens Services Bureau of Consular Affairs SA-29 4th Floor U*S* Department of State Washington D*C* 20520. You are advised to consult an attorney in the preparation and presentation of your appeal* The appeal must be in writing and it must state with particularity the reason why it is being made. It may be accompanied by a legal brief* Any statement of facts or circumstances not mentioned when the case was previously considered should be sworn to before an official authorized to take oaths and should be supported by the best evidence obtainable. For additional information about appeal procedures and to obtain copies of the relevant provisions of the Code of Federal Regulations consult the nearest American Embassy or Consulate or write to the Board of Appellate Review Department of State Washington D*C* 20520. U*S* Department of State BUREAU OF CONSULAR AFFAIRS CERTIFICATE OF LOSS OF NATIONALITY OF THE UNITED STATES This form is prescribed by the Secretary of State pursuant to Section 501 of the Act of October 14 1940 54 Stat. 1171 and Section 358 of the Act of June 27 1952 66 Stat. 272. DEPARTMENT USE ONLY of the United States of America Consulate at ss I.

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