Pta 20170502

Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ANALYSIS (PTA)
This form serves as the official determination by the DHS Privacy Office to
identify the privacy compliance requirements for all Departmental uses of
personally identifiable information (PII).
A Privacy Threshold Analysis (PTA) serves as the document used to identify
information technology (IT) systems, information collections/forms, technologies,
rulemakings, programs, information sharing arrangements, or pilot projects that involve
PII and other activities that otherwise impact the privacy of individuals as determined by
the Chief Privacy Officer, pursuant to Section 222 of the Homeland Security Act, and to
assess whether there is a need for additional Privacy Compliance Documentation. A PTA
includes a general description of the IT system, information collection, form, technology,
rulemaking, program, pilot project, information sharing arrangement, or other Department
activity and describes what PII is collected (and from whom) and how that information is
used and managed.
Please complete the attached Privacy Threshold Analysis and submit it to your
component Privacy Office. After review by your component Privacy Officer the PTA is sent
to the Department’s Senior Director for Privacy Compliance for action. If you do not have a
component Privacy Office, please send the PTA to the DHS Privacy Office:
Senior Director, Privacy Compliance
The Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
Tel: 202-343-1717
[email protected]

Upon receipt from your component Privacy Office, the DHS Privacy Office will review this
form and assess whether any privacy compliance documentation is required. If compliance
documentation is required – such as Privacy Impact Assessment (PIA), System of Records
Notice (SORN), Privacy Act Statement, or Computer Matching Agreement (CMA) – the DHS
Privacy Office or component Privacy Office will send you a copy of the relevant compliance
template to complete and return.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Privacy Threshold Analysis (PTA)

Specialized Template for
Information Collections (IC) and Forms
The Forms-PTA is a specialized template for Information Collections and Forms. This
specialized PTA must accompany all Information Collections submitted as part of the
Paperwork Reduction Act process (any instrument for collection (form, survey,
questionnaire, etc.) from ten or more members of the public). Components may use this PTA
to assess internal, component-specific forms as well.
Form Number:

N-565

Form Title:

Application for Replacement Naturalization Citizenship
Document
U.S. Citizenship and
Office:
Field Operations
Immigration Services
Division
(USCIS)

Component:

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
N-565, Application for Replacement Naturalization Citizenship
Document
OMB Control
1615-0091
OMB Expiration
May 31, 2017
Number:
Date:
Collection status: Extension
Date of last PTA (if February 3, 2010
applicable):
Name:
Office:
Phone:
Name:

PROJECT OR PROGRAM MANAGER
James Weidemann
Baltimore District Office
Title:
Adjudication Officer
202-740-1426
Email:
[email protected]
hs.gov

COMPONENT INFORMATION COLLECTION/FORMS CONTACT
Kerstin A. Jager

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

Office:

Phone:

Regulatory Coordination
Division
202-213-4211

Title:

Email:

Adjudication Officer

[email protected]
v
SPECIFIC IC/Forms PTA QUESTIONS

1. Purpose of the Information Collection or Form
a. Describe the purpose of the information collection or form. Please provide a
general description of the project and its purpose, including how it supports the DHS
mission, in a way a non-technical person could understand (you may use
information from the Supporting Statement).
If this is an updated PTA, please specifically describe what changes or upgrades are
triggering the update to this PTA.
USCIS is submitting an extension for the Form N-565 PTA with no substantial changes.
N-565, Application for Replacement Naturalization Citizenship Document
Section 343(a) of the Immigration and Nationality Act (INA) provides that if any
certificate of naturalization or citizenship issued to any citizen or any declaration of
intention furnished to any declarant is lost, mutilated, or destroyed, the citizen or
declarant may make application to the Secretary of Homeland Security for a new
certificate or declaration.

Form N-565 is used to apply to U.S. Citizenship and Immigration Services (USCIS) for a
replacement of one of the following:
1. Certificate of Naturalization;
2. Certificate of Citizenship;
3. Declaration of Intention;
4. Repatriation Certificate; or
5. To apply for a special certificate of naturalization to be recognized as a U.S. citizen
by a foreign country.
The form is provided by USCIS to determine the applicant’s eligibility for a replacement
document. An applicant may file for a replacement if he or she was issued one of the
documents described above and it was lost, mutilated, or destroyed, or if the applicant’s
name was changed by a marriage or by court order after the document was issued and
now seeks a document in the new name. If the applicant is a naturalized citizen who

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

desires to obtain recognition as a citizen of the United States by a foreign country, he or
she may apply for a special certificate for that purpose.
Relevant IT System

Data from Form N-565 is stored in CLAIMS3. Some N-565 data is currently stored in the
USCIS Electronic Immigration System (USCIS ELIS); USCIS is moving incrementally
toward data from all newly filed N-565’s being stored in USCIS ELIS. USCIS anticipates
that USCIS ELIS will become the primary system for storing data from newly filed N-565s
starting in FY 17 Q4.
Form N-565 and its supplemental evidence is stored in the applicant’s A-file.
b. List the DHS (or component) authorities to collect, store, and use this information.
If this information will be stored and used by a specific DHS component, list the
component-specific authorities.
INA Sec. 343. [8 U.S.C. 1454]
2. Describe the IC/Form
a. Does this form collect any
Personally Identifiable
Information” (PII 1)?

b. From which type(s) of
individuals does this form
collect information?
(Check all that apply.)

c. Who will complete and
submit this form? (Check
all that apply.)

☒ Yes
☐ No

☒ Members of the public
☒ U.S. citizens or lawful permanent
residents
☒ Non-U.S. Persons.
☐ DHS Employees
☐ DHS Contractors
☐ Other federal employees or contractors.

☒ The record subject of the form (e.g., the
individual applicant).
☒ Legal Representative (preparer, attorney,
etc.).
☐ Business entity.

1
Personally identifiable information means any information that permits the identity of an individual to be directly or indirectly inferred, including
any other information which is linked or linkable to that individual regardless of whether the individual is a U.S. citizen, lawful permanent resident,
visitor to the U.S., or employee or contractor to the Department.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

d. How do individuals
complete the form? Check
all that apply.

If a business entity, is the only
information collected business contact
information?
☐ Yes
☐ No
☐ Law enforcement.
☐ DHS employee or contractor.
☐ Other individual/entity/organization that is
NOT the record subject. Please describe.
Click here to enter text.

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☐ Online web form. (available and submitted via
the internet)
Provide link:

e. What information will DHS collect on the form? List all PII data elements on the
form. If the form will collect information from more than one type of individual,
please break down list of data elements collected by type of individual.
From the Applicant, this form collects:
• Full Legal Name
• Alias(es)
• Gender
• Height
• Marital Status
• Date of Birth
• Country of Birth
• Certificate Number
• Alien Registration Number (A-Number)
• Mailing Address
• Telephone Numbers
• Email Address
• Signature
This form collects the following processing information:
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

•
•
•

Basis for application
USCIS Office of Name Of Court that issued last certificate
Date Last Certificate was issued

From an Interpreter, this form collects:
• First and Last Name
• Business or Organization Name
• Mailing Address
• Telephone Numbers
• Email Address
• Signature
From a Preparer, this form collects:
• First and Last Name
• Business or Organization Name
• Mailing Address
• Telephone Numbers
• Email Address
• Signature

f. Does this form collect Social Security number (SSN) or other element that is
stand-alone Sensitive Personally Identifiable Information (SPII)? Check all that
apply.
☐ Social Security number
☐ DHS Electronic Data Interchange
Personal Identifier (EDIPI)
☒ Alien Number (A-Number)
☐ Social Media Handle/ID
☐ Tax Identification Number
☐ Known Traveler Number
☐ Visa Number
☐ Trusted Traveler Number (Global
☐ Passport Number
Entry, Pre-Check, etc.)
☐ Bank Account, Credit Card, or other
☐ Driver’s License Number
financial account number
☐ Biometrics
☐ Other. Please list:
g. List the specific authority to collect SSN or these other SPII elements.

INA Sec. 343. [8 U.S.C. 1454]
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

h. How will this information be used? What is the purpose of the collection?
Describe why this collection of SPII is the minimum amount of information
necessary to accomplish the purpose of the program.
Alien numbers, also called alien registration numbers, or A-numbers are identification
numbers issued to noncitizens by USCIS. The information collected in association with
the Alien Number is for tracking and record keeping purposes. The purpose of this will
allow internal employees the ability to track and work the application. This collection is
needed due to the sheer number of N-565s that are received and ingested into USCIS
systems.
i.

Are individuals
provided notice at the
time of collection by
DHS (Does the records
subject have notice of
the collection or is
form filled out by
third party)?

☒ Yes. Please describe how notice is provided.
The accompanying instructions for FormI-565
includes a Privacy Act Statement notifying the
individual of the authority, purpose, routine uses,
and disclosure of information Please note that the
N-565 can also be filled out by a third party
agency, after a properly executed G-28 is filed.
☐ No.

3. How will DHS store the IC/form responses?
a. How will DHS store
☒ Paper. Please describe.
the original,
Form N-565 is stored in the applicant’s A-file.
completed IC/forms?
☒ Electronic. Please describe the IT system that will

Privacy Threshold Analysis – IC/Form

store the data from the form.
Data from Form N-565 is stored in CLAIMS3. Some
N-565 data is currently stored in the USCIS
Electronic Immigration System (ELIS); USCIS is
moving incrementally toward data from all newly
filed N-565’s being stored in ELIS. USCIS
anticipates that ELIS will become the primary
system for storing data from newly filed N-565s
starting in FY 17 Q4.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

b. If electronic, how
does DHS input the
responses into the IT
system?

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?
d. What is the records
retention
schedule(s)? Include
the records schedule
number.
e. How do you ensure
that records are
disposed of or deleted
in accordance with

When Form N-565 is ingested at Lockbox, USCIS
will store a scanned version of the N-565 in the
Enterprise Data Management System (EDMS).

☒ Manually (data elements manually entered). Please
describe.
USCIS manually inputs N-565 data into CLAIMS3
when the form is filed with a Service Center.
☒ Automatically. Please describe.
As USCIS moves toward storing new N-565 data in
ELIS, these forms will be ingested at the Lockbox
instead of a Service Center, and the data will be
sent automatically from Lockbox into ELIS. USCIS
anticipates that the form will start being ingested
at the Lockbox in FY 17 Q4.

☒ By a unique identifier. 2 Please describe. If
information is retrieved by personal identifier, please
submit a Privacy Act Statement with this PTA.
Alien Registration Number (A-Number), Receipt
Number, and/or Name and Date of Birth are the
unique identifiers used to retrieve information
from CLAIMS3 and ELIS.
☐ By a non-personal identifier. Please describe.
Click here to enter text.
Form N-565: DAA-0566-2016-0016, Citizenship and
Naturalization Forms; published 9/9/2016
CLAIMS 3: DAA-0566-2016-0009

Local Records follows the Records Policy Manual
(RPM) as well as retention schedules as required and
set forth by Immigration Records and Identity
Management (IRIS) Directorate.

2
Generally, a unique identifier is considered any type of “personally identifiable information,” meaning any information that permits the identity
of an individual to be directly or indirectly inferred, including any other information which is linked or linkable to that individual regardless of
whether the individual is a U.S. citizen, lawful permanent resident, visitor to the U.S., or employee or contractor to the Department.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

the retention
schedule?
f. Is any of this information shared outside of the original program/office? If yes,
describe where (other offices or DHS components or external entities) and why.
What are the authorities of the receiving party?
☐ Yes, information is shared with other DHS components or offices. Please describe.
Click here to enter text.
☐ Yes, information is shared external to DHS with other federal agencies, state/local
partners, international partners, or non-governmental entities. Please describe.
Click here to enter text.
☒ No. Information on this form is not shared outside of the collecting office.

Please include a copy of the referenced form and Privacy Act Statement (if
applicable) with this PTA upon submission.

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD REVIEW
(TO BE COMPLETED BY COMPONENT PRIVACY OFFICE)
Component Privacy Office Reviewer:

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:
Have you approved a Privacy Act
Statement for this form? (Only
applicable if you have received a
waiver from the DHS Chief Privacy
Officer to approve component Privacy
Act Statements.)

Jenny Hoots

March 23, 2017
May 1, 2017

☒ Yes. Please include it with this PTA
submission.
☐ No. Please describe why not.
Click here to enter text.

Component Privacy Office Recommendation:
Please include recommendation below, including what existing privacy compliance
documentation is available or new privacy compliance documentation is needed.
The USCIS Office of Privacy recommendation is to designate Form N-565 as a privacy
sensitive form with coverage under the following:

PIAs
• DHS/USCIS/PIA-003(b) Integrated Digitization Document Management Program, which
covers the digitization and storage of forms in the Enterprise Document Management
System
• DHS/USCIS/PDHS/USCIS/PIA-016(a) Computer Linked Application Information
Management System (CLAIMS 3) and Associated Systems, which covers the processing
and adjudication of Form N-565
• DHS/USCIS/PIA-056 USCIS ELIS which covers the processing and adjudication of
electronically filed Form N-565
SORN
• DHS/USCIS-001 Alien File, Index, and National File Tracking System of Records, which
covers the collection, use, and storage of the Form N-565 and supplemental documents
in the A-File

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

•

DHS/USCIS-007 Benefits Information System, which covers the collection, use and
storage of data elements USCIS collects from benefit requestors, preparers, and
interpreters

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PRIVACY THRESHOLD ADJUDICATION
(TO BE COMPLETED BY THE DHS PRIVACY OFFICE)
DHS Privacy Office Reviewer:

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date
Privacy Sensitive IC or
Form:
Determination:

DHS IC/Forms Review:

Max Binstock
1142772
May 2, 2017
May 2, 2020

DESIGNATION
Yes If “no” PTA adjudication is complete.
☐ PTA sufficient at this time.
☐ Privacy compliance documentation determination in
progress.
☐ New information sharing arrangement is required.
☐ DHS Policy for Computer-Readable Extracts Containing SPII
applies.
☒ Privacy Act Statement required.
☒ Privacy Impact Assessment (PIA) required.
☒ System of Records Notice (SORN) required.
☐ Specialized training required.
☐ Other. Click here to enter text.
DHS PRIV has not received this ICR/Form.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
New e(3) statement is required.
Statement:
Click here to enter text.
PTA:
New system PTA required.
Click here to enter text.
PIA:
System covered by existing PIA
If covered by existing PIA, please list: DHS/USCIS/PIA-003(a)
Integrated Digitization Document Management Program (IDDMP);

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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

DHS/USCIS/PIA-016(a) Computer Linked Application Information
Management System (CLAIMS 3) and Associated Systems;
DHS/USCIS/PIA-056 USCIS ELIS
If a PIA update is required, please list: Click here to enter text.
SORN:
System covered by existing SORN
If covered by existing SORN, please list: DHS/USCIS/ICE/CBP-001 Alien
File, Index, and National File Tracking System of Records, November 21,
2013, 78 FR 69864; DHS/USCIS-007 Benefits Information System
October 19, 2016, 81 FR 72069
If a SORN update is required, please list: Click here to enter text.
DHS Privacy Office Comments:
Please describe rationale for privacy compliance determination above.

USCIS Privacy is submitting this PTA because Form N-565 is provided by USCIS to
determine the applicant’s eligibility for a replacement document. Form N-565 is
used to apply to U.S. Citizenship and Immigration Services (USCIS) for a replacement
of one of the following: Certificate of Naturalization; Certificate of Citizenship;
Declaration of Intention; Repatriation Certificate; or To apply for a special certificate
of naturalization to be recognized as a U.S. citizen by a foreign country.
PRIV finds that is a privacy sensitive system and a PIA is required because Form N565 collects PII from members of the public. PRIV concurs with USCIS Privacy that
the CLAIMS 3, IDDMP, and USCIS ELIS PIAs provide coverage for the recommended
reasons above.
PRIV finds that a SORN is required because Form N-565 retrieves information by a
unique identifier. PRIV agrees with USCIS Privacy that the BIS and A-File SORNs
provide coverage. DHS/USCIS/ICE/CBP-001 covers the collection, use, and storage of
the Form N-565 and supplemental documents in the A-File. DHS/USCIS-007 covers
the collection, use and storage of data elements USCIS collects from benefit
requestors, preparers, and interpreters.
PRIV finds that a PAS is required because Form N-565 collects information from
persons asked to provide personal information about themselves, which will go into
a system of records.

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