U.S. Embassy & Consulates
in Japan

AUTHORITIES: The information on this form is requested pursuant to U.S. Department of State authorities providing for consular and emergency assistance, including the Vienna Convention on Consular Relations and 22 U.S.C. § 3904 (Functions of Service);; 8 U.S.C. § 1104 (Powers and duties of Secretary of State); 8 U.S.C. §§ 1481 – 1488 (Loss of Nationality); 8 U.S.C. § 1501 (Certificate of Loss of Nationality of the United States);; 22 U.S.C. 211a (Authority to grant, issue and verify passports); 22 U.S.C. § 2705 (Documentation of Citizenship); 22 U.S.C. § 2671 (Emergency Expenditures); 22 U.S. Code § 4215 (Notarial acts, oaths, affirmations, affidavits, and depositions; fees); 22 U.S. Code § 4221 (Depositions and notarial acts; perjury).

PURPOSE: The information solicited on this form will be used in connection with requests for consular services.

ROUTINE USES: This information may be disclosed to another domestic government agency, a private contractor, a foreign government agency, or to a private person or private employer in accordance with certain approved routine uses. These routine uses include, but are not limited to, law enforcement activities, employment verification, fraud prevention, border security, counterterrorism, litigation activities, and activities that meet the Secretary of State’s responsibility to protect U.S. citizens and non-citizen nationals abroad. More information on the routine uses for the information collected can be found in System of Records Notices State-05, Overseas Citizen Services Records and other Overseas Records, and State-26, Passport Records.

DISCLOSURE: Providing this information is voluntary. Failure to provide all the information requested on this form may result in the individual and/or authorized representative’s inability to obtain relevant information regarding a consular service request.