Form N-565 Application for Replacement Naturalization/Citizenship D

Application for Replacement
Naturalization/Citizenship Document

USCIS
Form N-565

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

OMB No. 1615-0091
Expires 06/30/2019

Action Block

Fee Stamp

Returned
Resubmitted
Relocated
Sent
For Relocated
USCIS Received

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Only

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Applicant
Interviewed

Declaration of
Intention Verified by:

Citizenship Verified by:

Remarks

To Be Completed by an
Attorney or Accredited
Representative (if any)

Select this box if Attorney State Bar Number
Form G-28 is
(if applicable)
attached

Attorney or Accredited Representative
USCIS Online Account Number (if any)

►START HERE - Type or print in black ink.

Part 1. Information From Current Certificate or Declaration
1.

Your Full Name

Provide your full name exactly as it is printed on the certificate or declaration.
Family Name (Last Name)
Given Name (First Name)
2.

Country of Former Citizenship
or Nationality

3.

Certificate or Declaration
Number

Middle Name

4.

Alien Registration Number
(A-Number)
► A-

5.

Certificate or Declaration Issuance

Provide information about who issued your last certificate or declaration along with the date it was issued.
U.S. Citizenship and Immigration Services (USCIS) Office or Name of Court

Date (mm/dd/yyyy)

Part 2. Current Information About You
1.

Your Full Legal Name
Family Name (Last Name)

2.

Given Name (First Name)

Middle Name

Other Names You Have Used
Provide any other names you have used since birth, for any period of time, including aliases, maiden names, and nicknames. If
your answer is “none,” type or print “None.” If you need extra space to complete this section, use the space provided in Part 13.
Additional Information.
Family Name (Last Name)

Form N-565 06/13/17

Given Name (First Name)

Middle Name

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Part 2. Current Information About You (continued)
3.

(USPS ZIP Code Lookup)

Mailing Address
In Care Of Name
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

4.

ZIP Code

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Postal Code

Country

Has your marital status changed since your last document was issued?

Yes

No

NOTE: If you answered “Yes” to Item Number 4., provide your current marital status in Item Number 5. and attach a copy of
your marriage certificate, annulment decree, divorce decree, or spouse's death certificate.
5.

6.

Your Current Marital Status
Single
Married

Divorced

Marriage Annulled

Widowed

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

Yes

No

NOTE: If you answered “Yes” to Item Number 6., provide an explanation in Part 13. Additional Information or attach a
separate sheet of paper.

Part 3. Biographic Information
1.

Ethnicity (Select only one box)
Hispanic or Latino
Not Hispanic or Latino

2.

Race (Select all applicable boxes)

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

White

3.

Height

4.

Weight

5.

Eye Color (Select only one box)

6.

Feet

Black or African American

Inches

Pounds

Black

Blue

Brown

Maroon

Pink

Unknown/Other

Gray

Green

Hazel

Brown

Gray

Red

Hair Color (Select only one box)
Bald (No hair)

Black

Blond

Sandy

White

Unknown/Other

Form N-565 06/13/17

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Part 4. Type of Application
1.

I am applying for a (select only one box):
A.

New Declaration
New Certificate B.
New Certificate
New Certificate D.
C.
of Intention
of Citizenship
of Naturalization
of Repatriation
Special Certificate of Naturalization to Obtain Recognition of My U.S. Citizenship by a Foreign Country
E.
NOTE: If you selected Item E., skip the Basis for My Application section below and go to Part 9.

Basis for My Application

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Select all applicable boxes and provide explanations where requested.
2.

A.

My certificate or declaration was lost, stolen, or destroyed.

B. Provide an explanation of when, where, and how this happened.

3.

NOTE: If you selected Item A. in Item Number 2., go to Part 10. and attach a copy of the certificate or declaration
(if available), police report, and/or sworn statement.
My certificate or declaration is mutilated.
NOTE: If you selected Item Number 3., go to Part 10. and attach the original certificate or declaration.

4.

My certificate or declaration is incorrect due to a typographical or clerical error by USCIS.
NOTE: If you selected Item Number 4., go to Part 5. and attach the original certificate or declaration.

5.

My name has legally changed.

NOTE: If you selected Item Number 5., go to Part 6. and attach the original certificate or declaration and evidence of the
name change.
6.

My date of birth has legally changed through a court order or U.S. Government-issued document, and I am applying for a
replacement Certificate of Citizenship.
NOTE: If you selected Item Number 6., go to Part 7. and attach the original certificate or declaration and evidence of the date
of birth change.

7.

I am seeking to change the gender listed on my document.

NOTE: If you selected Item Number 7., go to Part 8. and attach the original certificate or declaration and evidence of the
gender change.
8.

A.

My reason for applying for a new document is not listed above.

B. Provide an explanation.

NOTE: If you selected Item A in Item Number 8., go to Part 10. and attach the original certificate or declaration and any
evidence documents.

Form N-565 06/13/17

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Part 5. Complete If Applying to Correct Your Document Due to a USCIS Typographical or
Clerical Error
NOTE: After completing this section, go to Part 10.
1.

Which information needs correcting? (select all applicable boxes)
Name
Date of Birth
Gender
Other

2.

Provide an explanation of what is incorrect on your current certificate or declaration and attach copies of any documents
supporting your request.

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Part 6. Complete If Applying for a New Document Because of a Name Change

NOTE: After completing this section, go to Part 10. If you are applying to correct your document due to a USCIS error, use Part 5.
1.

My name changed through (select only one box):
A.
Marriage, Divorce, or Annulment
B.
Date of Event (mm/dd/yyyy)

Court Order
Date of Court Order (mm/dd/yyyy)

NOTE: If you selected Item A., attach a copy of your marriage certificate, annulment decree, or divorce decree. If you selected
Item B., attach a copy of either the original or certified court document.
2.

My new legal name is:

Family Name (Last Name)

Given Name (First Name)

Middle Name

Part 7. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth
Change
NOTE: After completing this section, go to Part 10. If you are applying to correct your document due to a USCIS error, use Part 5.
1.

My date of birth changed through (select all applicable boxes):
A.
Court Order
B.
U.S. Government-Issued Document
Date of Court Order (mm/dd/yyyy)
Date of U.S. Government-Issued Document (mm/dd/yyyy)

NOTE: If you selected Item A., attach a copy of either the original or certified court document. If you selected Item B., attach a
copy of the document (for example, birth certificate, certificate recognizing the foreign birth, certificate of birth abroad, or other
similar vital records issued by the U.S. state where the child resided when the document was issued).
2.

My new date of birth is (as shown in the court order or U.S. Government-issued document): (mm/dd/yyyy)

Form N-565 06/13/17

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Part 8. Complete If Applying for a New Document Because of an Official Change in Gender
NOTE: After completing this section, go to Part 10. If you are applying to correct your document due to a USCIS error, use Part 5.
1.

My gender officially changed through (select all applicable boxes):
A.
Court Order
B.
Government-Issued Document C.
Reflecting the Gender Change

Licensed Health Care Professional's
Certification of Gender

NOTE: If you selected Item A., attach a copy of either the original or certified court document. If you selected Item B., attach a
copy of the document. If you selected Item C., attach the certification letter.
2.

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My current gender designation is:

Male

Female

Part 9. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States to
the Government of a Foreign Country
1.

Name of Foreign Country

2.

Information About Foreign Official

Provide the following information about the official of a foreign country who has requested this certificate (if known).
Family Name (Last Name)
Official Title
3.

Given Name (First Name)

Middle Name

Name of Government Agency

Foreign Official's Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

USCIS or Consular Official's Certification

NOTE: The USCIS or consular official's certification will be completed after USCIS adjudicates your Form N-565, if it is approved.
You do not need to obtain this signature before filing this application.
4.

USCIS or Consular Official's Certification
USCIS or Consular Official's Signature

Form N-565 06/13/17

Date of Signature (mm/dd/yyyy)

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Part 10. Applicant's Statement, Contact Information, Certification, and Signature
NOTE: Read the Penalties section of the Form N-565 Instructions before completing this section.
By signing this application, you state under penalty of perjury (28 U.S.C. section 1746) that all information and documentation
submitted with this application is complete, true, and correct. You also authorize the release of any information from your records that
USCIS may need to determine your eligibility for the immigration benefit you are seeking and consent to USCIS verifying such
information.
The Department of Homeland Security (DHS) has the authority to verify any information you submit to establish eligibility for the
immigration benefit you are seeking at any time. USCIS' legal authority to verify this information is in 8 U.S.C. sections 1103 and
1454 and 8 CFR parts 103 and 338. To ensure compliance with applicable laws and authorities, USCIS may verify information before
or after your case is decided.

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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 11. read to me every question and instruction on this application and my answer to every
question in
, 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 12.,
prepared this application for me based only upon information I provided or authorized.

Applicant's Contact Information
3.

Applicant's Daytime Telephone Number

5.

Applicant's Email Address (if any)

4.

Applicant's Mobile Telephone Number (if any)

Applicant's Declaration and 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 law.
I understand that USCIS will require me to appear for an appointment to take my biometrics and, at that time, 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 all of the information in my application and any document submitted with it were provided or
authorized by me, that I reviewed and understand all of the information contained in, and submitted with, my application and that all
of this information is complete, true, and correct.

Form N-565 06/13/17

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

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Part 11. 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)

2.

Interpreter's Business or Organization Name (if any)

Interpreter's Given Name (First Name)

Interpreter's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Province

Postal Code

ZIP Code

Country

Interpreter's Contact Information
4.

Interpreter's Daytime Telephone Number

6.

Interpreter's Email Address (if any)

5.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification
I certify, under penalty of perjury, that:
I am fluent in English and
, which is the same language specified in Part 10.,
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

Form N-565 06/13/17

Date of Signature (mm/dd/yyyy)

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Part 12. 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)

2.

Preparer's Business or Organization Name (if any)

Preparer's Given Name (First Name)

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Preparer's Mailing Address
3.

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Postal Code

Province

ZIP Code

Country

Preparer's Contact Information
4.

Preparer's Daytime Telephone Number

6.

Preparer's Email Address (if any)

5.

Preparer's Mobile Telephone Number (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.

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 need 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.

Signature of Preparer

Form N-565 06/13/17

Date of Signature (mm/dd/yyyy)

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Part 13. Additional Information
If you need extra space to provide any additional information within this application, use the space below. If you need more space
than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper.
Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item
Number to which your answer refers; and sign and date each sheet.
1.

Family Name (Last Name)

2.

A-Number (if any)

3.

A. Page Number
D.

4.

A. Page Number
D.

5.

A. Page Number
D.

6.

A. Page Number

Given Name (First Name)

Middle Name

► A-

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B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

B. Part Number

C. Item Number

D.

Form N-565 06/13/17

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