Table of changes form

Table of Changes-FORM

Form I-565, Application for Replacement Naturalization/Citizenship Document

OMB No. 1615-0091

4/13/2016

Reason for Revision: Incorporation of Standard Language

Page Number and Location	Current Text	Proposed Text
Page 1	For USCIS Use Only Returned Resubmitted Relocated Sent Relocated Received Applicant Interviewed Declaration of Intention Verified by: Citizenship Verified by: Fee Stamp Remarks: Action Block	[Page 1 ] [No Change]
Page 1	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 ELIS Account Number (if any) START HERE- Type or print in black ink.	[Page 1] To be completed by an attorney or BIA-accredited representative (if any) [No Change] Attorney or Accredited Representative USCIS Online Account Number (if any) [No Change]
Page 1	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) 6. Mailing Address In Care Of Name Street Number and Name Apt. Ste. Flr. ________ City or Town State ZIP Code Province Postal Code Country	[Page 1] 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) 6. Mailing Address In Care Of Name Street Number and Name Apt. Ste. Flr. ________ City or Town State ZIP Code Province Postal Code Country
Page 2, Part 2. Type of Application	1. I hereby apply for: (select only one box) 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 Item Number 2 and complete Part 3., Part 8., and Part 9.) 2. Basis for application. Select all that apply: [] 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 document(s)). [] My name has legally changed (Complete Part 3., Part 5., and Part 9., and attach the certificate and document(s)). [] My date of birth has legally changed due to a court order or other state-issued documents (Complete Part 3., Part 6., and Part 9., and attach the certificate and document(s)). NOTE: Only applicants applying for a replacement Certificate of Citizenship may select this option. My gender has legally changed (Complete Part 3., Part 7., and Part 9., and attach the certificate and document(s)). Other (Explain) (Complete Part 3., Part 4., and Part 9., and attach the document(s)).	[Page 2] [No Change] 2. Basis for application. (Select all applicable boxes): [No Change]
Page 2, Part 3. Processing Information	Gender Male Female Height Feet____ Inches____ Marital Status Single Married Divorced Widowed My last certificate or Declaration of Intention was issued to me by: USCIS Office or Name of Court Date (mm/dd/yyyy) Name in Which the Document Was Issued Other Names I Have Used (if none, type or print “None”) Family Name (Last Name) Given Name (First Name) Middle Name 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	[Page 2] Part 3. Processing Information [No Change]
Page 3, 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. __________________________________	[Page 3] Part 4. Complete If Applying To Correct Your Document [No Change]
Page 3, 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)	[Page 3] Part 5. Complete If Applying for a New Document Because of a Name Change [No Change]
Page 3, Part 6. Complete If Applying for a New Certificate of Citizenship Because of a Date of Birth Change	Date of birth changed by: [] Court Order (Attach a certified copy of the document.) (mm/dd/yyyy) [] 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.) (mm/dd/yyyy)	[Page 3] Part 6. Complete If Applying for a New Certificate of Citizenship Because of a Date of Birth Change [No Change]
Page 3, 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): [] Court Order (Attach a certified copy of the document) [] Amended birth certificate (Attach a certified copy of the document) [] Other official documentation recognizing the new gender by U.S. State, local jurisdiction, or foreign state, such as a passport or driver's license. [] Medical certification by a licensed physician (doctor of medicine (M.D.) or doctor of osteopathy)	[Page 3] [No Change]
Page 3, 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____________________ 3. Address of Foreign Official Street Number and Name Suite Number City State ZIP Code Province Postal Code Country USCIS or Consular Official’s Certification USCIS or Consular Official’s Signature Date of Signature (mm/dd/yyyy)	[Page 3] 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 [No Change]
Page 4, Part 9. Applicant’s Statement, Contact Information, Acknowledgement of Appointment at USCIS Application Support Center, Certification, and Signature	NOTE: Read the information on penalties in 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. If applicable, select the box for Item Number 2. 1. Applicant’s Statement Regarding the Interpreter A. [Check Box] I can read and understand English, and have read and understand every question and instruction on this application, as well as my answer to every question. I have read and understand the Acknowledgement of Appointment at USCIS Application Support Center. B. [Check Box] The interpreter named in Part 10. has read to me every question and instruction on this application, as well as my answer to every question, in [Fillable Field], a language in which I am fluent. I understand every question and instruction on this application as translated to me by my interpreter, and have provided complete, true, and correct responses in the language indicated above. The interpreter named in Part 10. has also read the Acknowledgement of Appointment at USCIS Application Support Center to me, in the language in which I am fluent, and I understand this Application Support Center (ASC) Acknowledgement as read to me by my interpreter. 2. Applicant’s Statement Regarding the Preparer [Check Box] I have requested the services of and consented to [Fillable Field], who [checkbox] is [checkbox] is not an attorney or accredited representative, preparing this application for me. This person who assisted me in preparing my application has reviewed the Acknowledgement of Appointment at USCIS Application Support Center with me, and I understand the ASC Acknowledgement. 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) Acknowledgement of Appointment at USCIS Application Support Center I, [Auto-populate Field with Applicant Full Name], understand that the purpose of a USCIS ASC appointment is for me to provide fingerprints, photograph, and/or signature and to re-affirm that all of the information in my application is complete, true, and correct and was provided by me. I understand that I will sign my name to the following declaration which USCIS will display to me at the time I provide my fingerprints, photograph, and/or signature during my ASC appointment: By signing here, I declare under penalty of perjury that I have reviewed and understand my application, petition, or request as identified by the receipt number displayed on the screen above, and all supporting documents, applications, petitions, or requests filed with my application, petition, or request that I (or my attorney or accredited representative) filed with USCIS, and that all of the information in these materials is complete, true, and correct. I also understand that when I sign my name, provide my fingerprints, and am photographed at the USCIS ASC, I will re-affirming that I willingly submit this application; I have reviewed the contents of this application; all of the information in my application are complete, true, and correct; and if I was assisted in completing this application, the person assisting me also reviewed this Acknowledgement of Appointment at USCIS Application Support Center with me. 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 and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. I furthermore 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. I certify, under penalty of perjury, that the information in my application and any document submitted with my application were provided by me and are complete, true and correct. Applicant’s Signature 1. 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.	[Page 4] 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 question in [Fillable Field], a language in which I am fluent, and I understood everything. 2. Applicant’s Statement Regarding the Preparer [] At my request, the preparer named in Part 11., [Fillable Filed], prepared this application for me based only upon information I provided or authorized. 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. 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.
Page 6, Part 10. Interpreter’s Contact Information, Certification, and Signature	Provide the following information concerning 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 [Sub-header] 3. Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Province Postal Code Country Interpreter’s Contact Information 4. Interpreter’s Daytime Telephone Number 5. Interpreter’s Email Address (if any) Interpreter’s Certification I certify that: I am fluent in English and [Fillable Field] which is the same language provided in Part 9., Item B. in Item Number 1.; I have read to this applicant every question and instruction on this application, as well as the answer to every question, in the language provided in Part 9., Item B. in Item Number 1.; and I have read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant in the same language provided in Part 9., Item B. in Item Number 1. The applicant has informed me that he or she understands every instruction and question on the application, as well as the answer to every question, and the applicant verified the accuracy of every answer; and The applicant has also informed me that he or she understands the ASC Acknowledgement and that by appearing for a USCIS ASC biometric services appointment and providing his or her fingerprints, photograph, and/or signature, he or she is re-affirming that the contents of this application and all supporting documentation are complete, true, and correct. Interpreter’s Signature 6. Interpreter’s Signature Date of Signature (mm/dd/yyyy)	[Page 5 ] 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. [fillable field] 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) Interpreter’s Certification I certify, under penalty of perjury, that: I am fluent in English and [Fillable Field], 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. Interpreter’s Signature 7. Interpreter’s Signature Date of Signature (mm/dd/yyyy)
Page 7, Part 11. Contact Information, Statement, Certification, and Signature of the Person Preparing this Application, If Other Than the Applicant	Provide the following information concerning 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 (if any) Preparer’s Mailing Address 3. Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Province Postal Code Country Preparer’s Contact Information 4. Preparer’s Daytime Telephone Number 5. Preparer’s Fax Number 6. Preparer’s Email Address (if any) 7.A. [Check Box] I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.B. [Check Box] I am an attorney or accredited representative and my representation of the applicant in this case [Check Box] extends [Check Box] does not extend beyond the preparation of this application. NOTE: If you are an attorney or accredited representative whose representation extends beyond preparation of this application, you must submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative, with this application. Preparer’s Certification By my signature, I certify, swear, or affirm, under penalty of perjury, that I prepared this application on behalf of, at the request of, and with the express consent of the applicant. I completed this application based only on responses the applicant provided to me. After completing the application, I reviewed it and all of the applicant’s responses with the applicant, who agreed with every answer on the application. If the applicant supplied additional information concerning a question on the application, I recorded it on the application. I have also read the Acknowledgement of Appointment at USCIS Application Support Center to the applicant and the applicant has informed me that he or she understands the ASC Acknowledgement. Preparer’s Signature 8. Signature of Preparer Date of Signature (mm/dd/yyyy)	[Page 6] 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. [fillable field] 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) Preparer’s Statement 7.A. [] I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant’s consent. 7.B. [] I am an attorney or accredited representative and my representation of the applicant in this case [] extends [] does not extend beyond the preparation of this application. 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. 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. Preparer’s Signature Date of Signature (mm/dd/yyyy)

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