Form DS-4194 Request for Authentications Service

U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE

OMB Control Number: 1405-0254
Expiration Date: 01-31-2025
Estimated Burden: 10 minutes

Please type or print legibly using black ink only. If you make an error, complete a new form. Do not correct.

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.

INSTRUCTIONS
Complete one copy of this form per individual or company to be submitted with your documents and payment. Walk-In Service: A maximum of 15 documents are allowed
for submission per customer/company for walk-in services. Mail-In Service: Attach continuation sheet(s) for mail-in requests exceeding 15 documents. Failure to submit
this form with your documents and payment will result in a denial of your request and your documents will be returned.
For Mail-In Service, please mail form , documents, and payment to: Department of State
Office of Authentications
44132 Mercure Circle
P.O. Box 1206
Sterling, VA 20166-1206

Section 1. Customer Contact Information: Provide individual's full name or company's name (complete spelling). Provide Email address, telephone
numbers (home, work and/or cell) and mailing address. If the document(s) were mailed or hand carried on behalf of a federal agency for official
Government business, please specify agency's name, bureau, and/or office acronyms and provide mailing address.
Section 2. Shipping Details (for Mail-In Service): If shipping the document(s), 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 Other). Indicate the complete address the document(s)
will be returned to for proper delivery. All documents will be returned to one location. We do not return documents via FedEx and in multiple envelopes.
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 a document, 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) and telephone numbers (daytime, evening, or cell number).
Section 4. Document Information: Indicate the country (or countries) of use, the number of documents, and the document type.
Section 5. Projected Cost: 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. Pay the total amount shown in the estimated cost field (the exact amount is required). Allowable
payment methods include money orders and checks (personal, corporate, certified, cashier's, traveler's) and should be made 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. Do not send cash by mail.

WARNING

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 a
document when it has good reason to believe that the certification is desired for an unlawful or improper purpose.

PRIVACY ACT STATEMENT
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 shared with 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 to solicit requests for related
services. The information may also be shared for law enforcement, fraud prevention, border security, counterterrorism, litigation
activities, and administrative purposes. More information on the Routine Uses for this collection can be found in 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 information may result in processing delays.

PAPERWORK REDUCTION ACT 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 are not required to provide 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 01-2023

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OMB Control Number: 1405-0254
Expiration Date: 01-31-2025
Estimated Burden: 10 minutes

U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE

CLEAR

Please type or print legibly using black ink only. If you make an error, complete a new form. Do not correct.

Service Number
SECTION 1: CUSTOMER CONTACT INFORMATION

Customer Name (Last, First, MI)

Suffix/Prefix Email

Home or Work

Phone: Cell

Extension

Date (MM/DD/YYYY)

Case Type (For Federal Agency - Must Be Official Business)

Individual

Company

Federal Agency (specify)

Mailing Address
Line 1
Line 2

State/Province

City

Country

Zip Code

SECTION 2: SHIPPING DETAILS
(Please complete this section ONLY if you are shipping the documents)
Delivery Method: ☐ Self-Addressed Stamped Envelope ☐ UPS ☐ DHL ☐ Other Tracking Number:
SECTION 3: COURIER/REPRESENTATIVE CONTACT INFORMATION
Are you submitting/retrieving this request on behalf of
another individual? ☐ YES ☐ NO

Name (Last, First, MI)

Company

Phone

Extension

SECTION 4: DOCUMENT INFORMATION

Country of Use
(Outside U.S.)

Document Type

Number of
Documents

(Note: Use Continuation Sheet for mail-in
requests exceeding 15 documents)

Processing Fee
Per Document

Document Label

(For Official Use Only)

Received:
OP:
Date:
CK#:
Cash:
DE:
Date:
No FEE
No COU
No DOC
No RTN ENV

SECTION 5: PROJECTED COST
Document Total:

For Official Use Only
Specialist Notes:
Date:

Incorrect Fees
Call

Estimated Cost:

Problem with Doc
Rejection
Email
Specialist:

Date:

Call

Email

Specialist:

Date:

Call

Email

Specialist:

DS-4194 01-2023

x $20.00 per
document

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OMB Control Number: 1405-0254
Expiration Date: 01-31-2025
Estimated Burden: 10 minutes

U.S. Department of State

REQUEST FOR AUTHENTICATIONS SERVICE

Please type or print legibly using black ink only. If you make an error, complete a new form. Do not correct.

Service Number
(Note: Use Continuation Sheet for mail-in
requests exceeding 15 documents)

CONTINUATION SHEET (SECTION 4: DOCUMENT INFORMATION)
Country of Use
(Outside U.S.)

Document Type

Number of
Documents

Document Label

Processing Fee
Per Document

(For Official Use Only)

Received:
OP:
DATE:
CK#:
Cash:
DE:
DATE:
No FEE
No COU
No DOC
No RTN ENV

DS-4194 01-2023

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