Please fill the form of the secretary of state of USD

U.S. Department of State
REQUEST FOR AUTHENTICATIONS SERVICE
SECTION 1: CUSTOMER CONTACT INFORMATION
Name (Last, First, MI)
Suffix/Prefix
E-mail
Home Phone
Extension
Cell Phone
Extension
Work Phone
Extension
Case Type (If Federal Agency Must Be Official Business)
Specify
Country
Formal Mailing Address
Line 1
Line 2
City
State
ZIP Code
SECTION 2: COURIER/REPRESENTATIVE CONTACT INFORMATION
Are you submitting/retrieving this request on behalf of another individual?
Name (Last, First, MI)
Company
Phone Number
Extension
SECTION 3: SHIPPING DETAILS (FOR MAILED IN REQUESTS ONLY)
Delivery Method
Specify
Tracking Number
Shipping Address
Shipping Address
Same address as above
Country
Line 1
Line 2
City
State
ZIP Code
SECTION 4: DOCUMENT INFORMATION (CONTINUED ON NEXT PAGE)
Country
Number of Documents
Document Type
Document Label (Official Use Only)
SECTION 5: PROJECTED COST
Total Number of Documents
Estimated Cost
Page 1 of 2
DS-4194
02-2012
Name (Last, First, MI)
Suffix/Prefix
E-mail
SECTION 4: ADDITIONAL DOCUMENTS (CONTINUED)
Country
Number of Documents
Document Type
Document Label (Official Use Only)
DS-4194
Page 2 of 2
U.S. Department of State
REQUEST FOR AUTHENTICATIONS SERVICE
INSTRUCTIONS
PURPOSE
Form DS-4194 is used by the U. S. Department of State for documents submitted by U.S. citizens and foreign nationals. The Authentications Office is
responsible for signing and issuing certificates under the Seal of the U. S. Department of State for documents being submitted to foreign countries.
INSTRUCTIONS
Complete one copy of this form for yourself or your company to be submitted with your documents and payment. You must submit a new cover letter
for each request. Failure to do so will result in your case being rejected and documents being returned.
WARNING
Any false statement or concealment of a material fact may result in a delay or un-authenticated documentation.
FORM
DS-4194
SECTION 1: REQUESTOR'S CONTACT INFORMATION
Provide individual's full name or company's name (complete spelling). Indicate e-mail 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 indicate agency name, bureau
and/or office acronyms. Provide formal mailing address (include street address, city or town, zip code, province or country).
SECTION 2: SUBMITTER'S 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 State issued identification is required.
Provide individual's full name or company's name (complete spelling). Indicate e-mail address; telephone number(s) day time, evening or cell number.
SECTION 3: METHOD OF RETURN (MAIL-IN)
Indicate delivery method (type of mail service used to return the document). If this information is available, provide a tracking number and include all
letters and numbers (i.e., DOS, USPS, FED/EX, UPS, DHL & Others). Indicate the complete address that the document (s) will be returned to
for proper delivery.
It is imperative that the complete address is entered accurately! (i.e., street address, city, state, ZIP code & country). REVIEW INFORMATION FOR
ACCURACY!
Please note: All documents submitted will be returned to one location.
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 person for walk-in services).
SECTION 5: METHOD OF PAYMENT
Please note:The authentication processing fee is $8.00 per document, not per page. This fee will be charged regardless of whether you receive an
authentication certification or a correspondence letter. This change in policy will take effect on April 1, 2012. 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 "U.S.
Department of State."
Walk-in service only:In addition to the payment methods noted above; Credit Cards and Debit/Check Cards (VISA, MasterCard, American Express,
Discover) are accepted.
DS-4194
Instructions Page 1 of 1
02-2012