Form N-565 Application for Replacement Naturalization/Citizenship D

OMB No. 1615-0091; Expires 04/30/10

N-565, Application for Replacement
Naturalization/Citizenship Document

Department of Homeland Security
U.S. Citizenship and Immigration Services

START HERE - Please type or print in black ink.
Part 1.
Information about you.
Family Name

For USCIS Use Only
Receipt

Returned
Middle Name

Given Name

Address - In care of:
Street Number and Name

Apt #

City or town

Resubmitted

State or Province
Zip or Postal Code

Country
Date of Birth (mm/dd/yyyy)

Country of Birth

Certificate Number

A#

Telephone # (with area/country codes)

E-Mail Address (if any)

Reloc Sent

Reloc Rec'd

Part 2. Type of application.
1. I hereby apply for: (check one)
a.
b.
c.
d.
e.

New Certificate of Citizenship.
New Certificate of Naturalization.
New Certificate of Repatriation.
New Declaration of Intention.
Special Certificate of Naturalization to obtain recognition of my U.S. citizenship by a
foreign country.

2. Basis for application: (If you checked other than "e" in Part 1, check one)
a.

My certificate is/was lost, stolen or destroyed (attach a copy of the certificate if you
have one). Explain when, where and how.

Applicant
Interviewed

Declaration of Intention verified by
Citizenship verified by

Remarks
b.
c.
d.

My certificate is mutilated (attach the certificate).
My name has been changed (attach the certificate).
My certificate or declaration is incorrect (attach the documents).

Part 3. Processing information.
Marital
Male
Height
Single
Status
Female
Married
My last certificate or Declaration of Intention was issued to me by:
USCIS Office or Name of Court
Date (mm/dd/yyyy)

Gender

Widowed
Divorced
Action Block

Name in which the document was issued:
Other names I have used (if none, so indicate):
Since becoming a citizen, have you lost your citizenship in any manner?
No

Yes (attach an explanation)

Part 4. Complete if applying for a new document
because of a name change.
Name changed to present name by: (check one)
Marriage or divorce on (month/day/year)
(Attach a copy of marriage or divorce certificate)
Court Decree (month/day/year)
(Attach a copy of the court decree)

To Be Completed by
Attorney or Representative, if any.
Fill in box if G-28 is attached to
represent the applicant.
VOLAG#
ATTY State License #
Form N-565 (Rev. 07/30/07)Y

Part 5. 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 the documents supporting your request.

Part 6. Complete if applying for a special certificate of recognition
as a citizen of the U.S. by the government of a foreign country.
Name of Foreign Country
Information about official of the country who has requested this certificate (if known)
Name

Official Title

Government Agency:
Room #

Address: Street #
and Name
City

State/
Province

Country

Zip or
Postal Code

Part 7. Signature.

Read the information on penalties in the instructions before completing this part. If you are going to file this
application at a USCIS office in the United States sign below. If you are going to file this application at a USCIS
office abroad, sign it in front of a USCIS or Consular Official.

I certify, or if outside the United States, I swear or affirm, under penalty of perjury under the laws of the United States of America, that this
application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records which U.S.
Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking.
Signature

Date

Signature of USCIS
or Consular Official
NOTE:

Print Name

Date

If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible
for a certificate and this application may be denied.

Part 8. Signature of person preparing form, if other than above. (Sign below.)
I declare that I prepared this application at the request of the above person and it is based on all information of which I have knowledge.
Signature
Firm Name and Address

Print Your Name

Date
Telephone Number (with area code)

E-Mail Address (if any)

Form N-565 (Rev. 07/30/07)Y Page 2