Form N-565 Application for Replacement Naturalization/Citizenship D

OMB No. 1615-0091; Expires 07/31/2012

Form 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

Given Name

For USCIS Use Only
Receipt

Returned
Middle Name

Address - In care of:
Street Number and Name

Apt. Number

City or Town

Resubmitted

State or Province
Zip or Postal Code

Country
Date of Birth (mm/dd/yyyy)

Country of Birth

Certificate Number

A-Number

Telephone Number (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. (Skip Number 2 and go to Part 3)

Applicant
Interviewed

Declaration of Intention verified by

2. Basis for application: (Refer to the instructions for additional information.)
Citizenship verified by
a.

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

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 Form G-28 is attached
to represent the applicant.
VOLAG#
ATTY State License #
Form N-565 (Rev. 07/08/11) 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:
Suite Number

Address: Street Number 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 (mm/dd/yyyy)

Signature of USCIS
or Consular Official
NOTE:

Print Your Name

Date (mm/dd/yyyy)

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 the applicant
I declare that I prepared this application at the request of the applicant and it is based on all information of which I have knowledge.
Signature

Firm Name and Address

Print Your Name

Date (mm/dd/yyyy)

Telephone Number (with area code)

E-Mail Address (if any)

Form N-565 (Rev. 07/08/11) Y Page 2