Form DS-4194 Request for Authentications Service

OMB CONTROL NO. 1405-xxxx
EXPIRES: XX/XX/20XX
Estimated Burden: 10 minutes

U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE
USE OF THIS FORM

This form is used by individuals, institutions, and government agencies to request authentication and/or apostille certificates under
the seal of the U.S. Department of State for documents used for legal and administrative purposes abroad. For information or
questions, visit www.travel.state.gov or call 202-485-8000.

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INSTRUCTIONS

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Complete one copy of this form per individual or company to be submitted with your documents and payment. You can include up
to 15 different document types per form. Failure to submit this form with your documents and payment will result in your request
being denied and documents returned.
Section 1. Customer Contact Information: Provide individual's full name or company's name (complete spelling). Indicate email address; telephone number(s) home, work and/or cell. If the document(s) were mailed or hand carried for a Federal
Agency, for Official Government business, please specify agency's name, bureau, and/or office acronyms.

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Section 2. Shipping Details: If you will be shipping the document(s), please indicate delivery method (type of mail service used to
return the document). If available, provide a tracking number including all letters and numbers (i.e., DOS, USPS, UPS, DHL,
and Others). Indicate the complete address the document(s) will be returned to for proper delivery.

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Section 3. Courier/Representative Contact Information: If you are submitting/or retrieving a request on behalf of someone other
than yourself or a company, please provide specific and detailed information. The full name of the individual's or company's name
is required to properly search the database. If you are retrieving document(s), your name must appear in section 2 of the intake
form and U.S. government or state issued identification is required. Provide individual's full name or company's name (complete
spelling). Indicate telephone number(s) daytime, evening, or cell number.

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Section 4. Document Information: Indicate the country (or countries) of use, the number of documents, and the document type. (A
maximum of 15 documents are allowed per customer/company for walk-in services).

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Section 5. Projected Cost: Please Note: The authentication process fee is $20.00 per document, not per page. This fee will be
charged regardless of whether you receive an authentication certification or a correspondence letter. Please pay the total amount
shown in the estimated cost field. (The exact amount is required.) Allowable payment methods include U.S. Postal Money Orders,
checks (personal, corporate, certified, cashiers, travelers) all payable to the "U.S. Department of State." Walk-in service only: In
addition to the payment methods noted above; Cash (exact amount), Credit Cards and Debit/Check Cards (Visa, MasterCard,
American Express, and Discover) are accepted.

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WARNING

PRIVACY ACT STATEMENT

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False statements made knowingly and willfully in this application, are punishable by fine and/or imprisonment under U.S. law
including the provisions of 18 U.S.C. 1001. Also, be advised that pursuant to 22 CFR § 131.2, the Department of State will not certify
to a document when it has good reason to believe that the certification is desired for an unlawful or improper purpose.

AUTHORITIES: Collection of the information solicited on this form is authorized by R.S. 203; 63 Stat. 111, as amended, sec. 4; 62
Stat. 946, sec. 1733; 66 Stat. 174, secs.104, 332; 66 Stat. 252; 8 U.S.C. 1104; 8 U.S.C. 1443; 8 U.S.C. 2657; 8 U.S.C. 2658; 28
U.S.C. 1733; 22 CFR Part 131.
PURPOSE: The purpose for soliciting the information requested on this form is to ensure that the documentation
submitted is the same as the documentation received and processed by the Office of Authentications.
ROUTINE USES: The information solicited on this form may be made available as a routine use to other government agencies and
private contractors to assist the U.S. Department of State in issuing certificates under the Seal of the U.S. Department of State and
requests for related services, and for law enforcement, fraud prevention, border security, counterterrorism, litigation activities, and
administrative purposes. For a more detailed listing of the routine uses to which this information may be put, please see the
Department of State's Prefatory Statement of Routine Uses (Public Notice 6290 of July 15, 2008) and the listing of routine uses set
forth in the System of Records Notices for Overseas Citizen Services Records and Other Overseas Records (State-05) and
Passport Records (State-26).
DISCLOSURE: Providing information on this form is voluntary. However, failure to provide the information requested on this form
could result in the Office of Authentications’ inability to process your request.

PAPERWORK REDUCTION ACT (PRA) STATEMENT
Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time
required for searching existing data sources, gathering the necessary data, providing the information and/or documents required,
and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB
control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send
them to: Passport Forms Officer, U.S. Department of State, Bureau of Consular Affairs, Passport Services, Office of Program
Management and Operational Support, 44132 Mercure Cir, PO Box 1199, Sterling, Virginia 20166-1227.

DS-4194 XX-20XX

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OMB CONTROL NO. 1405-xxxx
EXPIRES: XX/XX/20XX
Estimated Burden: 10 minutes

U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE
RESET FORM

Service Number

SECTION 1: CUSTOMER CONTACT INFORMATION
Person of Contact’s Name (Last, First, MI)

Line 1

Home or Work

City

Date (mm/dd/yyyy)

Case Type (If Federal Agency Must Be Official Business)
☐ Individual ☐ Company ☐ Federal Agency Specify

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Line 2

Email

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Cell
Phone
Numbers:
Mailing Address

Suffix/Prefix

State/Province

Country

Zip Code

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SECTION 2: SHIPPING DETAILS

(Please complete this section ONLY if you are shipping the documents)

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Delivery Method: ☐ Self-Addressed Stamped Envelope ☐ UPS ☐ DHL ☐ Other

Tracking Number:

SECTION 3: COURIER/REPRESENTATIVE CONTACT INFORMATION

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Are you submitting/retrieving this request on behalf of
another individual? ☐ YES ☐ NO

Name (Last, First, MI)

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Company

Phone Number

Extension

Document Type

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SECTION 4: DOCUMENT INFORMATION
Country of Use

Number of
Documents

Processing Fee
Per Document

Document Label
(For Official Use Only)

Select One

Select One

0

Select One

Select One

0

Select One

Select One

0

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

0

$20

DE:

Select One

Select One

0

$20

DATE:

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

0

$20

Select One

Select One

Received:

$20

OP:

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DATE:
CK#:

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Rejection

0

Date:

Call

Email/

Specialist:

Date:

Call

Email/

Specialist:

Date:

Call

Email/

Specialist:

DS-4194 XX-20XX

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Document Total:
Problem with Doc

$20

No CK

No DOC

No RTN ENV

$20
0
SECTION 5: PROJECTED COST

Specialist Notes:
Incorrect Fees

$20

x $20.00 per
document

Estimated Cost:

$00

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