US Citizenship
Questionnaire

[The following is a transcript of a questionnaire which was used by the US consulate in Toronto when dealing with possible dual citizenship situations. To the best of my knowledge, this questionnaire is no longer routinely used, but it may still be of some interest.]

The following information is needed to determine your present citizenship status and/or your entitlement to consular services as a citizen of the United States. You may want to consult with an attorney before completing this form. If you have any questions about the form, you should discuss them with a member of our consular staff before filling it out. Use extra paper as needed and attach any supporting documents to this form.

1.

Name: ____________________

2.

Date and Place of Birth ____________________

3.

If not born in the U.S., citizenship acquired by:

• Naturalization on __________ before the (court) at (city)

• Birth outside the U.S. to U.S. citizen parent(s)

4.

Last U.S. passport Number __________ issued on __________ at __________.

5.

Give dates and countries of residence outside the U.S. since birth.

6.

Answer this question only if at birth you became a citizen of the United States and of another country (for example, because you were born in the United States and thereby became an American citizen, but one or both of your parents were citizens of another country and you also acquired that country's citizenship at birth).

Have you sought or claimed the benefits of the nationality of a foreign state between December 24, 1952 and October 10, 1978? Examples of such benefits are possession or use of that country's passport, owning property in an area where noncitizens cannot own property, and obtaining employment for which noncitizens are ineligible.

Circle one: YES NO

If you answered yes, please explain the benefits you sought or claimed.

7.

Have you performed any of the following acts?

a) Been registered or naturalized as a citizen of a foreign state? Give Exact Date: __________

b) Taken an oath or made an affirmation or other formal declaration of allegiance to a foreign state? Give Exact Date: __________

c) Served in the Armed Forces of a foreign state? Give Exact Date: __________

d) Accepted, served in, or performed the duties of any office, post or employment under the government of a foreign state? Give Exact Date: __________

e) Renounced United States nationality at a United States Consulate or Embassy? Give Exact Date: __________

f) Have you ever been issued a Certificate of Loss of Nationality by the United States Government OR had any previous contact with the United States Government concerning your United States citizenship status? Give Exact Date: __________

8.

If you answer to All of the questions asked in item 7, above, is no, please sign here and do not complete the rest of this questionnaire.

(Signature) ____________________ (Date) __________

9.

You should be aware that under United States law a citizen who has performed any of acts specified in item 7 with the intention of relinquishing United States citizenship may have thereby lost United States citizenship. If you voluntarily performed an act/s specified in item 7 with the intention of relinquishing United States citizenship, you may sign the statement below and return this form to us. We will then prepare the necessary forms to document your loss of United States citizenship.

STATEMENT OF VOLUNTARY RELINQUISHMENT OF UNITED STATES NATIONALITY

"I, ____________________ performed the act of expatriation indicated in item 7_____ voluntarily and with the intention of relinquishing my United States nationality."

(Signature) ____________________ (Date) __________

If you believe that expatriation has not occurred, either because the act you performed was not voluntary or because you did not intend to relinquish United States citizenship you should complete the remainder of this form.

10.

a) Are you a national or citizen of any country other than the United States?

b) If yes, of what country?

c) If yes, did you acquire that citizenship:

• by birth in the foreign country
• by marriage
• by naturalization or registration on (date)
• other (explain)

11.

a) When did you first become aware that you might be a United States citizen? (Give approximate date.)

b) What initiated your present contact with this office regarding your United States citizenship?

c) How did you find out you were a United States citizen? (For example did you always know you were a United States citizen? If not when did you learn about your citizenship? Did someone tell you that you were a citizen?)

12.

a) Since the performance of the act specified in Question 7 of this questionnaire, have you informed any official of Canada or the U.S. that you were a U.S. citizen?

b) Since your performance of the act specified in item 7 of this questionnaire, have you visited the U.S. and, if so, what documentation did you use, if any, to identify yourself at the border? Any documentary evidence to substantiate your statement is requested.

13.

a) Describe as specifically as you can the act/s you performed as indicated in item 7. For example, by what means or in what sort of proceeding were you naturalized as a citizen of the foreign state? What was the nature of the oath you took?

b) In what foreign army did you serve? What rank did you hold?

c) What employment did you have and what were your responsibilities?

14.

a) Describe in as much detail as possible the circumstances under which you performed the act/s indicated in item 7. Did you perform the act/s voluntarily? If no, in what sense was your performance of the act/s involuntary?

b) What was your intent in performing the act/s?

c) Did you know that by performing the act/s described in item 7 you might lose United States citizenship? EXPLAIN YOUR ANSWER.

15.

Please indicate what ties you retain with the United States.

a) File U.S. income tax returns? If yes, submit copies of your latest returns.

b) Vote as an absentee voter? If yes, when did you last vote?

c) Register your Canadian born children with the U.S. Consulate/Embassy? If yes, explain when and where.

d) Own property and/or maintain a residence in the United States?

e) Family or social ties?

16.

Please indicate what ties you have to the country (Canada) where you performed the act indicated in item 7.

a) File income tax returns?

b) Vote in elections?

c) Own property?

d) Family or social ties? Explain: __________

Your answers on this form will become part of the official record in your case. Before signing this form, read over your answers to make certain that they are as complete and accurate as possible. If you would like to provide information that you believe relevant to a determination of your citizenship status but that is not called for by any of the questions on this form, you may attach separate sheets setting forth that information.

(Signature) ____________________ (Date) __________
 

Copyright © 1991-2006 Richard B. Wales. All rights reserved.