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Fillable Printable Form N-565

Fillable Printable Form N-565

Form N-565

Form N-565

Application for Replacement
Naturalization/Citizenship Document
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form N-565 06/13/17 N
USCIS
Form N-565
OMB No. 1615-0091
Expires 06/30/2019
Page 1 of 7
For
USCIS
Use
Only
Part 1. Information About You
3. Country of Birth2. Date of Birth (mm/dd/yyyy)
4. Certificate Number
6. Mailing Address
City or TownStateZIP Code
In Care Of Name
Street Number and NameApt.Flr.Ste.
Family Name (Last Name)
1. Full Legal Name
Given Name (First Name)Middle Name
START HERE - Type or print in black ink.
Remarks:
Action Block
Relocated Received
Relocated Sent
Fee Stamp
Resubmitted
Returned
Applicant Interviewed
Citizenship Verified by:
Declaration of Intention Verified by:
A-
5. Alien Registration Number (A-Number)
ProvinceCountry Postal Code
To be completed
by an attorney or
BIA-accredited
representative (if any)
Select this box if
Form G-28 is
attached to represent
the applicant.
Attorney State Bar Number
(if applicable)
Attorney or Accredited Representative
USCIS Online Account Number (if any)
Form N-565 06/13/17 NPage 2 of 7
Part 2. Type of Application
2. Basis for application(Select all applicable boxes):
My certificate was lost, stolen, or destroyed. Explain when, where, and how. (Complete Part 3. and Part 9., and attach
a copy of the certificate (if any), police report, or sworn statement.)
My certificate is mutilated. (Complete Part 3., Part 9., and attach the certificate.)
My certification or declaration is incorrect due to typographical/clerical error. (Complete Part 3., Part 4., and Part 9.,
and attach the documents.)
Other: Explain (Complete Part 3., Part 4., and Part 9., and attach the documents.)
My gender has legally changed. (Complete Part 3., Part 7., and Part 9., and attach the certificate and documents.)
My date of birth has legally changed due to a court order or other state-issued documents. NOTE: Only applicants
applying for a replacement Certificate of Citizenship may select this option. (Complete Part 3., Part 6., and Part 9.,
and attach the certificate and documents.)
My name has legally changed. (Complete Part 3., Part 5., and Part 9., and attach the certificate and documents.)
Part 3. Processing Information
Gender1.Height3.
USCIS Office or Name of Court
6.
Other Names I Have Used (if none, type or print "None")
8.Since becoming a citizen, have you lost or renounced your citizenship in any manner?
7.
Name in Which the Document Was Issued
5.Date (mm/dd/yyyy)4.
Marital Status
My last certificate or Declaration of Intention was issued to me by:
FeetInches
2.
SingleMaleMarriedFemaleWidowedDivorced
NoYes (attach an explanation)
Family Name (Last Name)Given Name (First Name)Middle Name
A.
B.
C.
D.
E.
F.
G.
1. I hereby apply for (select only one box):
New Certificate of CitizenshipA.
New Certificate of NaturalizationB.
New Certificate of Repatriation
C.
New Declaration of Intention
D.
Special Certificate of Naturalization to obtain recognition of my
U.S. citizenship by a foreign country. (Skip Item Number 2. and
complete Part 3., Part 8., and Part 9.)
E.
Form N-565 06/13/17 NPage 3 of 7
Part 7. Complete If Applying for a New Document Because of a Change in Gender
Evidence of official recognition of gender change recognized by(select all applicable boxes):
Amended birth certificate (Attach a certified copy of the document)
Medical certification by a licensed physician (doctor of medicine (M.D.) or doctor of osteopathy (D.O.)
Other official documentation recognizing the new gender by U.S. state, local jurisdiction, or foreign state, such as a
passport or driver's license.
Court Order
(Attach a certified copy of the document)
Part 8. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States by
the Government of a Foreign Country
Name of Foreign Country
2.
Information about official of the country who has requested this certificate (if known)
1.
Family Name (Last Name)Given Name (First Name)Middle Name
Official Title
Name of Government Agency
Part 5. Complete If Applying for a New Document Because of a Name Change
B.
A.
B.
C.
D.
(mm/dd/yyyy)
(mm/dd/yyyy)Court Order (Attach a certified copy of the document)
Date of birth changed by:
Part 6. Complete If Applying for a New Certificate of Citizenship Because of a Date of Birth Change
Name changed because of(select only one box):
(mm/dd/yyyy)Court Order (Attach a certified copy of the document)
Marriage or divorce on(Attach a copy of marriage or divorce certificate)(mm/dd/yyyy)A.
A.
B.
State-issued document (For example, birth certificate, certificate recognizing
the foreign birth, certificate of birth abroad, or other similar records issued
by the child's state of residence.)
Part 4. Complete If Applying To Correct Your Document
If you are applying for a new certificate or Declaration of Intention because your current one is incorrect, explain why it is incorrect
and attach copies of any documents supporting your request.
Form N-565 06/13/17 NPage 4 of 7
Part 9. Applicant's Statement, Contact Information, Certification, and Signature
The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every
Applicant's Statement Regarding the Preparer
understood everything.
, a language in which I am fluent, and I
B.
I can read and understand English, and I have read and understand every question and instruction on this application and
my answer to every question.
A.
NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.
NOTE: Read the Penalties section of the Form N-565 Instructions before completing this part.
Applicant's Statement Regarding the Interpreter
question in
2.
At my request, the preparer named in Part 11.,
prepared this application for me based only upon information I provided or authorized.
,
Applicant's Contact Information
3.
5.
4.Applicant's Daytime Telephone Number
Applicant's Email Address (if any)
Applicant's Mobile Telephone Number (if any)
Date of Signature USCIS or Consular Official's Signature
USCIS or Consular Official's Certification
(mm/dd/yyyy)
Applicant's Statement
3.Address of Foreign Official
City or TownStateZIP Code
Street Number and NameApt.Flr.Ste.
ProvinceCountry Postal Code
Part 8. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States by
the Government of a Foreign Country (continued)
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
Applicant's Certification
1.
4.
I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and enforcement of U.S. immigration laws.
Form N-565 06/13/17 NPage 5 of 7
Date of Signature Applicant's Signature
(mm/dd/yyyy)
NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the
Instructions, USCIS may deny your application.
6.
Applicant's Signature
I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the
information contained in, and submitted with, my application, and that all of this information is complete, true, and correct.
Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued)
I understand that USCIS may require me to appear for an appointment to take my biometrics (fingerprints, photograph, and/or
signature) and, at that time, if I am required to provide biometrics, I will be required to sign an oath reaffirming that:
1)I reviewed and provided or authorized all of the information in my application;
2)I understood all of the information contained in, and submitted with, my application; and
3)All of this information was complete, true, and correct at the time of filing.
Part 10. Interpreter's Contact Information, Certification, and Signature
3.
City or TownStateZIP Code
Street Number and NameApt.Flr.Ste.
ProvinceCountry
Postal Code
Interpreter's Mailing Address
Interpreter's Family Name (Last Name)1.
Provide the following information about the interpreter.
Interpreter's Given Name (First Name)
Interpreter's Business or Organization Name (if any)2.
Interpreter's Full Name
Number
Interpreter's Contact Information
4.
6.
Interpreter's Daytime Telephone Number
Interpreter's Email Address (if any)
5.Interpreter's Mobile Telephone Number (if any)
Form N-565 06/13/17 NPage 6 of 7
Date of SignatureInterpreter's Signature
(mm/dd/yyyy)
Interpreter's Signature
7.
Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and , which is the same language specified in Part 9.,
Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this
application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question,
and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer.
Part 10. Interpreter's Contact Information, Certification, and Signature (continued)
Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Preparer's Contact Information
Preparer's Daytime Telephone Number
Preparer's Email Address (if any)
Preparer's Mobile Telephone Number (if any)4.
6.
5.
3.
City or TownStateZIP Code
Street Number and NameApt.Flr.Ste.
ProvinceCountry Postal Code
Preparer's Mailing Address
Provide the following information about the preparer.
1.Preparer's Family Name (Last Name)
Preparer's Given Name (First Name)
2.Preparer's Business or Organization Name (if any)
Preparer's Full Name
Number
Form N-565 06/13/17 NPage 7 of 7
By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I
completed this application based only on information that the applicant provided to me or authorized me to obtain or use.
Preparer's Certification
Preparer's Signature
8.Signature of Preparer
Date of Signature
(mm/dd/yyyy)
Preparer's Statement
I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.
NOTE: If you are an attorney or accredited representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative
with this application.
7.
I am an attorney or accredited representative and my representation of the applicant in this case
does not extend beyond the preparation of this application.extends
Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
A.
B.
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