N-565 Form TOC

TABLE OF CHANGES – FORM

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

OMB Number: 1615-0091

11/05/2018

Reason for Revision: Comprehensive revision to include standard language updates.

Legend for Proposed Text:

• Black font = Current text

• Purple font = Standard language

• Red font = Changes

Current Page Number and Section	Current Text	Proposed Text
Page 1, To be completed by an attorney or BIA-accredited representative (if any)	[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 Online Account Number (if any)	[Page 1] To Be Completed by an Attorney or Accredited Representative (if any) Select this box if Form G-28 is attached Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any)
Page 2, Part 3. Processing Information	[Page 2] Part 3. Processing Information 6. Name in Which the Document Was Issued My last certificate or Declaration of Intention was issued to me by: 4. USCIS Office or Name of Court 5. Date (mm/dd/yyyy) 1. Gender Male Female 2. Height Feet Inches 3. Marital Status Single Married Divorced Widowed 7. Other Names I Have Used (if none, type or print “None”) Family Name (Last Name) [x2] Given Name (First Name) [x2] Middle Name [x2] 8. Since becoming a citizen, have you lost or renounced your citizenship in any manner? Yes (attach an explanation) No	[Page 1] 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) Middle Name 2. Country of Former Citizenship or Nationality 3. Certificate or Declaration Number 4. Alien Registration Number (A-Number) 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) [Deleted]
Page 1, Part 1. Information About You	[Page 1] Part 1. Information About You 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name 6. Mailing Address In Care of Name Street Number and Name Apt./Ste./Flr. [Fillable field] City or Town State ZIP Code Province Postal Code Country 2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Certificate Number 5. Alien Registration Number (A-Number)	[Page 1] Part 2. Current Information About You 1. Your Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name 2. 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) [x2] Given Name (First Name) [x2] Middle Name [x2] [Page 2] 3. Mailing Address In Care of Name Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country 4. 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. Your Current Marital Status Single Married Divorced Widowed Marriage Annulled 6. 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. [Deleted]
New		[Page 2] 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 Black or African American Native Hawaiian or Other Pacific Islander White 3.  Height  Feet__ Inches __ 4.  Weight    Pounds _ ­_ _ 5.  Eye Color (Select only one box) Black Blue Brown Gray Green Hazel Maroon Pink Unknown/Other 6.  Hair Color (Select only one box) Bald (No hair) Black Blond Brown Gray Red Sandy White Unknown/Other
Page 2, Part 2. Type of Application	[Page 2] Part 2. Type of Application 1. I hereby apply for (select only one box): A. New Certificate of Citizenship B. New Certificate of Naturalization C. New Certificate of Repatriation D. New Declaration of Intention E. 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 applicable boxes): A. 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.) [Fillable field] B. My certificate is mutilated. (Complete Part 3., Part 9., and attach the certificate.) C. My certification or declaration is incorrect due to typographical/clerical error. (Complete Part 3., Part 4., and Part 9., and attach the documents.) D. My name has legally changed. (Complete Part 3., Part 5., and Part 9., and attach the certificate and documents.) E. My date of birth has legally changed due to a court order or other state-issued documents. NOTE: Only applicants applying for a replacement Certificate of Citizenship may select this option. (Complete Part 3., Part 6., and Part 9., and attach the certificate and documents.) F. My gender has legally changed. (Complete Part 3., Part 7., and Part 9., and attach the certificate and documents.) G. Other: Explain (Complete Part 3., Part 4., and Part 9., and attach the documents.) [Fillable field]	[Page 3] Part 4. Type of Application 1. I am applying for a (select only one box): A. New Certificate of Citizenship B. New Certificate of Naturalization C. New Certificate of Repatriation D. New Declaration of Intention E. Special Certificate of Naturalization to Obtain Recognition of My U.S. Citizenship by a Foreign Country NOTE: If you selected Item E., skip the Basis for My Application section below and go to Part 9. Basis for My Application 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. [Fillable field] 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. 3. 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. [Page 3] 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. [Fillable field] 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.
Page 3, Part 4. Complete If Applying to Correct Your Document	[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 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.
Page 3, Part 5. Complete If Applying for a New Document Because of a Name 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 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 Date of Event (mm/dd/yyyy) B. 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
Page 3, Part 6. Complete If Applying for a New Certificate of Citizenship Because of a Date of Birth 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) B. 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.)	[Page 4] 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 Date of Court Order (mm/dd/yyyy) B. U.S. Government-Issued Document 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)
Page 3, Part 7. Complete If Applying for a New Document Because of a Change in Gender	[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): A. Court Order (Attach a certified copy of the document) B. Amended birth certificate (Attach a certified copy of the document) C. Other official documentation recognizing the new gender by U.S. state, local jurisdiction, or foreign state, such as a passport or driver’s license. D. Medical certificate by a licensed physician (doctor of medicine (M.D.) or doctor of osteopathy (D.O.)	[Page 4] 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 [Deleted] B. Government-Issued Document Reflecting the Gender Change C. 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. My current gender designation is: Male Female
Page 3 - 4, 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	[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 [Page 4] 3. Address of Foreign Official Street Number and Name Apt./Ste./Flr. [Fillable field] City or Town State ZIP Code Province Postal Code Country USCIS or Consular Official’s Certification 4. USCIS or Consular Official’s Signature Date of Signature (mm/dd/yyyy)	[Page 4] 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) Given name (First Name) Middle Name Official Title Name of Government Agency 3. Foreign Official’s Address Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal 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 Signature Date of Signature (mm/dd/yyyy)
Pages 4 - 5, Part 9. Applicant’s Statement, Contact Information, Certification, and Signature	[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 Field], 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. [Page 5] 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 5] 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. 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 [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 12., [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 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. 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.
Pages 5 - 6, Part 10. Interpreter’s Contact Information, Certification, and Signature	[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) [Page 6] 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 6] 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) 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. Number 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 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 Date of Signature (mm/dd/yyyy)
Pages 6 - 7, Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[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) [Page 7] 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 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)	[Page 7] 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) 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. Number 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. 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. Preparer’s Signature Date of Signature (mm/dd/yyyy)
New		[Page 8] 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) [Auto-populated field] Given Name (First Name) [Auto-populated field] Middle Name [Auto-populated field] 2. A-Number (if any) [Auto-populated field] 3. A. Page Number B. Part Number C. Item Number D. [Fillable field] 4. A. Page Number B. Part Number C. Item Number D. [Fillable field] 5. A. Page Number B. Part Number C. Item Number D. [Fillable field] 6. A. Page Number B. Part Number C. Item Number D. [Fillable field]

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