Form N 565 – Fill Out and Use This PDF

	Application for Replacement
	Naturalization/Citizenship Document	USCIS
	Department of Homeland Security	Form N-565
		OMB No. 1615-0091
	U.S. Citizenship and Immigration Services	Expires 06/30/2019

Citizenship Verified by:

►START HERE - Type or print in black ink.

Part 1. Information About You

1.Full Legal Name

Family Name (Last Name)

Given Name (First Name)

Middle Name

2.

Date of Birth (mm/dd/yyyy)

3. Country of Birth

4.

Certificate Number

5.

Alien Registration Number (A-Number)

► A-

6.Mailing Address In Care Of Name

Street Number and Name						Apt. Ste. Flr.
City or Town						State		ZIP Code
Province		Postal Code		Country

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Part 2. Type of Application

2.Basis for application (Select all applicable boxes):

Part 3. Processing Information

6.Name in Which the Document Was Issued

7.Other Names I Have Used (if none, type or print "None")

Family Name (Last Name)		Given Name (First Name)		Middle Name

8. Since becoming a citizen, have you lost or renounced your citizenship in any manner?

Yes (attach an explanation)

No

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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.

Part 5. Complete If Applying for a New Document Because of a Name Change

Name changed because of (select only one box):
A.	Marriage or divorce on (Attach a copy of marriage or divorce certificate)	(mm/dd/yyyy)
B.	Court Order (Attach a certified copy of the document)	(mm/dd/yyyy)

Part 6. Complete If Applying for a New Certificate of Citizenship Because of a Date of Birth Change

Date of birth changed by:

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):

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

1.	Name of Foreign Country
Information about official of the country who has requested this certificate (if known)
2.	Family Name (Last Name)		Given Name (First Name)				Middle Name
	Official Title				Name of Government Agency

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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)

3.Address of Foreign Official

Street Number and Name						Apt. Ste. Flr.
City or Town						State		ZIP Code
Province		Postal Code		Country

USCIS or Consular Official's Certification

4. USCIS or Consular Official's Signature		Date of Signature
		(mm/dd/yyyy)

Part 9. Applicant's Statement, Contact Information, Certification, and Signature

NOTE: Read the Penalties section of the Form N-565 Instructions before completing this part.

Applicant's Statement

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

1.Applicant's Statement Regarding the Interpreter

A. 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.

B.	The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every

Applicant's Contact Information

3. Applicant's Daytime Telephone Number		4. Applicant's Mobile Telephone Number (if any)

5.Applicant's Email Address (if any)

Applicant's Certification

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.

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.

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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.

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.

Applicant's Signature

6. Applicant's Signature		Date of 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.

Part 10. Interpreter's Contact Information, Certification, and Signature

Provide the following information about the interpreter.

Interpreter's Full Name

1. Interpreter's Family Name (Last Name)		Interpreter's Given Name (First Name)

2.Interpreter's Business or Organization Name (if any)

Interpreter's Mailing Address

3. Street Number and Name							Apt. Ste. Flr.		Number
	City or Town						State		ZIP Code
	Province		Postal Code		Country

Interpreter's Contact Information

4. Interpreter's Daytime Telephone Number		5. Interpreter's Mobile Telephone Number (if any)

6.Interpreter's Email Address (if any)

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Part 10. Interpreter's Contact Information, Certification, and Signature (continued)

Interpreter's Certification

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.

Interpreter's Signature

7. Interpreter's Signature		Date of Signature
		(mm/dd/yyyy)

Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant

Provide the following information about the preparer.

Preparer's Full Name

1. Preparer's Family Name (Last Name)			Preparer's Given Name (First Name)

2.Preparer's Business or Organization Name (if any)

Preparer's Mailing Address

3. Street Number and Name							Apt. Ste. Flr.		Number
	City or Town						State		ZIP Code
	Province		Postal Code		Country

Preparer's Contact Information

4. Preparer's Daytime Telephone Number		5. Preparer's Mobile Telephone Number (if any)

6.Preparer's Email Address (if any)

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Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant (continued)

Preparer's Statement

Preparer's Certification

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 Signature

8. Signature of Preparer		Date of Signature
		(mm/dd/yyyy)

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