Pta

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:
Form Title:
Component:

N-565
Application for Replacement Naturalization Citizenship Document
U.S. Citizenship and
Office:
Service Center
Immigration Services
Operations
(USCIS)

IF COVERED BY THE PAPERWORK REDUCTION ACT:
Collection Title:
N-565, Application for Replacement Naturalization Citizenship
Document
June 30, 2019
OMB Control
1615-0091
OMB Expiration
Number:
Date:
Collection status: Extension
Date of last PTA (if May 8, 2018
applicable):

Name:
Office:
Phone:

Name:

PROJECT OR PROGRAM MANAGER
William Ward
Service Center Operations
Title:
Adjudication Officer
202-272-1712
Email:
[email protected]
ov
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:

Adjudication Officer

Email:

[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.
2018 Update:
USCIS is updating Form N-565 to include following updates:
 Include the collection of biometric processing information: Ethnicity, race,
height, weight, eye color, and hair color.
 Clarify reasons for the application and provide more detailed instructions. For
example, USCIS is standardizing the Biometric Services appointment language
on forms to notify individuals that biometric information may be required.
 The Immigration Biometric and Background Check SORN is added as coverage.

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

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

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
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
Individuals may use myUSCIS online account to electronically fileN-565. Once submitted,
the N-565is transferred to USCIS ELIS for case processing.
Previously, the N-565 was processed and stored in CLAIMS 3. Beginning May 2018,
USCIS will begin processing the Form N-565 in the USCIS Electronic Immigration System
(USCIS ELIS). Form N-565’s previously ingested into CLAIMS 3 will continue being
processed in CLAIMS 3 until the form is approved/denied. All newly filed Form N-565’s
will solely be processed in USCIS ELIS. USCIS anticipates that USCIS ELIS will become the
primary system for storing data from newly filed N-565s starting in FY 18 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” (PII1)?

☒ Yes
☐No

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

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

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

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

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

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

☒ Paper.
☒ Electronic. (ex: fillable PDF)
☒ Online web form. (available and submitted via
the internet)
Provide link: https://www.uscis.gov/n-565

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

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
 Ethnicity
 Height
 Weight
 Race
 Eye Color
 Hair Color
This form collects the following processing information:
 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
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

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]
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.

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

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 Form I-565
includes a Privacy Notice notifying the individual
of the authority, purpose, routine uses, and
disclosure of information Please note that the N565 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
store the data from the form.
N-565 data will be stored in both CLAIMS 3 and
USCIS ELIS. No new forms will be processed using
CLAIMS 3 and forms filed prior to May 2018 will
continue being processed in CLAIMS 3. All new
forms will solely be processed in USCIS ELIS.
☒ Scanned forms (completed forms are scanned into
an electronic repository). Please describe the
electronic repository.
When Form N-565 is ingested at Lockbox, USCIS
will store a scanned version of the N-565 in the
Electronic Immigration System (ELIS).
b. If electronic, how
does DHS input the
responses into the IT
system?

☐ Manually (data elements manually entered). Please
describe.
☒ 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 USCIS ELIS..

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

c. How would a user
search the
information
submitted on the
forms, i.e., how is the
information
retrieved?

☒ 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

d. What is the records
retention
schedule(s)? Include
the records schedule
CLAIMS 3: DAA-0566-2016-0009
number.
e. How do you ensure
Local Records follows the Records Policy Manual
that records are
(RPM) as well as retention schedules as required and
disposed of or deleted
set forth by Immigration Records and Identity
in accordance with
Management (IRIS) Directorate.
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.

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

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:

Maisonobe G. Fokwa Kengne

Date submitted to component Privacy
Office:
Date submitted to DHS Privacy Office:

September 25, 2018

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.)

November 16, 2018
☒ 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/PDHS/USCIS/PIA-016(a) Computer Linked Application Information
Management System (CLAIMS 3) and Associated Systems, which covers the forms
ingested into CLAIMS 3 for processing and adjudication prior to May 2018
• DHS/USCIS/PIA-056 USCIS ELIS which covers the processing and adjudication of
electronically filed Form N-565, as well as paper forms received after May 2018
• DHS/USCIS/PIA-071 MyUSCIS Account Experience, which covers the completion and
online submission of certain USCIS forms.
USCIS Office of Privacy is concurrently submitting the USCIS ELIS and myUSCIS Account
Experience PIA Appendices to account for these new forms.
SORN

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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-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
DHS/USCIS-007 Benefits Information System, which covers the collection, use and
storage of data elements USCIS collects from benefit requestors, preparers, and
interpreters
DHS/USCIS-018 Immigration Biometric and Background Check (IBBC) System of
Records, which covers the collection, use, and maintenance of biometric 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

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

Hannah Burgess

PCTS Workflow Number:
Date approved by DHS Privacy Office:
PTA Expiration Date

1171840
November 19, 2018
November 19, 2021

DESIGNATION
Privacy Sensitive IC or
Form:

Yes If “no” PTA adjudication is complete.

Determination:

☐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 IC/Forms Review:

Choose an item.

Date IC/Form Approved Click here to enter a date.
by PRIV:
IC/Form PCTS Number: Click here to enter text.
Privacy Act
Choose an item.
Statement:
Click here to enter text.
PTA:
Choose an item.
Click here to enter text.
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Privacy Office
U.S. Department of Homeland Security
Washington, DC 20528
202-343-1717, [email protected]
www.dhs.gov/privacy

PIA:

System covered by existing PIA
If covered by existing PIA, please list: DHS/USCIS/PDHS/USCIS/PIA016(a) Computer Linked Application Information Management System
(CLAIMS 3) and Associated Systems;
DHS/USCIS/PIA-056 USCIS ELIS;
DHS/USCIS/PIA-071 MyUSCIS Account Experience
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, September 18,
2017, 82 FR 43556;
DHS/USCIS-007 Benefits Information System, October 19, 2016 81 FR
72069;
DHS/USCIS-018 Immigration Biometric and Background Check (IBBC)
System of Records, July 31, 2018, 83 FR 36950
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 is submitting this PTA to discuss updates to Form N-565, Application for
Replacement Naturalization Citizenship Document. USCIS is standardizing the biometric
services appointment language on forms to notify individuals biometric information may
be required, and is including the collection of biometric processing information (such as
height, weight, eye color) on this form.
The DHS Privacy Office agrees that this is a privacy sensitive collection, requiring PIA
coverage. Coverage for the forms ingested into CLAIMS 3 for processing and adjudication
prior to May 2018 continues to be provided by DHS/USCIS/PDHS/USCIS/PIA-016(a)
Computer Linked Application Information Management System (CLAIMS 3). Coverage for
the processing and adjudication of the electronically filed forms, as well as paper forms
received after May 2018, is provided by DHS/USCIS/PIA-056 USCIS ELIS, and coverage for
the online completion and submission of the forms is provided by DHS/USCIS/PIA-071
MyUSCIS Account Experience.
SORN coverage is also required, and is provided by DHS/USCIS-001 Alien File and
DHS/USCIS-007 Benefits Information System. DHS/USCIS-018 Immigration Biometric and
Background Check (IBBC) System of Records has been added as additional coverage.

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