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

Action Block

Fee Stamp

Returned

OMB No. 1615-0091
Expires 02/28/2027

Resubmitted
Relocated
Sent
For Relocated
USCIS Received

Use
Only

DRAFT
NOT FOR
PRODUCTION
08/19/2024
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)

Middle Name (if applicable)

2.

Date of Birth on Certificate or Declaration
(mm/dd/yyyy)

3.

Country of Birth

4.

Country of Former Citizenship or Nationality

5.

Certificate or Declaration Number

6.

Alien Registration Number (A-Number) (if any)
► A-

7.

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 (Do not provide a nickname)
Family Name (Last Name)

Form N-565 Edition 04/01/24

Given Name (First Name)

Middle Name (if applicable)

Page 1 of 7

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

Other Names Used
Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete
this section, use the space provided in Part 12. Additional Information.
Family Name (Last Name)

3.

Given Name (First Name)

Middle Name (if applicable)

DRAFT
NOT FOR
PRODUCTION
08/19/2024

Current Mailing Address

In Care Of Name (if any)

Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

Postal Code

Province

4.

5.

Your Current Marital Status
Single
Married

Divorced

Widowed

ZIP Code

Country

Marriage Annulled

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 5., provide an explanation in Part 12. Additional Information or attach a
separate sheet of paper.

Part 3. Type of Application

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

New Certificate of Citizenship

1.d.

New Declaration of Intention

1.b.

New Certificate of Naturalization

1.e.

1.c.

New Certificate of Repatriation

Special Certificate of Naturalization to Obtain Recognition of My
U.S. Citizenship by a Foreign Country

NOTE: If you selected Item 1.e., skip to Part 8.

Basis for My Application
Select all applicable boxes, provide explanations and attach the original certificate or declaration where requested.
2.a.

My certificate or declaration was lost, stolen, or destroyed.
(1) Provide an explanation of when, where, and how this happened.

NOTE: If you selected Item Number 2.a., go to Part 9. and attach a copy of the certificate or declaration (if available), police
report, and/or sworn statement.

Form N-565 Edition 04/01/24

Page 2 of 7

Part 3. Type of Application (continued)
2.b.

My certificate or declaration is mutilated.
NOTE: If you selected Item Number 2.b., go to Part 9. and attach the original certificate or declaration.

2.c.

My certificate or declaration is incorrect due to a typographical or clerical error by USCIS.
NOTE: If you selected Item Number 2.c., go to Part 4. and attach the original certificate or declaration.

2.d.

My name has legally changed.

DRAFT
NOT FOR
PRODUCTION
08/19/2024

NOTE: If you selected Item Number 2.d., go to Part 5. and attach the original certificate or declaration and evidence of the
name change.
2.e.

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 2.e., go to Part 6. and attach the original certificate and evidence of the date of birth change.

2.f.

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

NOTE: If you selected Item Number 2.f., go to Part 7. and attach the original certificate or declaration.
2.g.

My reason for applying for a new document is not listed above.
(1) Provide an explanation.

NOTE: If you selected Item Number 2.g., go to Part 9. and attach the original certificate or declaration and any evidence
documents.

Part 4. Complete If Applying to Correct Your Document Due to a USCIS Typographical or
Clerical Error
NOTE: After completing this section, go to Part 9.
1.

What was the typographical or clerical error in your document that needs to be corrected? (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.

Form N-565 Edition 04/01/24

Page 3 of 7

Part 5. Complete If Applying for a New Document Because of a Name Change
NOTE: After completing this section, go to Part 9. If you are applying to correct your document due to a USCIS error, use Part 4.
My name changed through (select only one box):
1.a.
Marriage, Divorce, or Annulment
1.b.
Date of Event (mm/dd/yyyy)

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

DRAFT
NOT FOR
PRODUCTION
08/19/2024

NOTE: If you selected Item Number 1.a., attach a copy of your marriage certificate, annulment decree, or divorce decree. If
you selected Item Number 1.b., attach a copy of either the original or certified court document.

Part 6. 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 9. If you are applying to correct your document due to a USCIS error, use Part 4.
My date of birth changed through (select all applicable boxes):
1.a.

Court Order

Date of Court Order
(mm/dd/yyyy)

1.b.

U.S. Government-Issued Document
Date of U.S. Government-Issued
Document (mm/dd/yyyy)

NOTE: If you selected Item Number 1.a., attach a copy of either the original or certified court document. If you selected Item
Number 1.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)

Part 7. Complete If Applying for a New Document Listing a Different Gender

NOTE: After completing this section, go to Part 9. If you are applying to correct your document due to a USCIS error, use Part 4.
1.

The gender designation that I want listed on my new document is:

Male

Female

Another Gender Identity

Part 8. 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

Form N-565 Edition 04/01/24

Given Name (First Name)

Middle Name (if applicable)

Name of Government Agency

Page 4 of 7

Part 8. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States to
the Government of a Foreign Country (continued)
3.

Foreign Official's Address
Street Number and Name

Apt. Ste. Flr. Number

City or Town

State

ZIP Code

DRAFT
NOT FOR
PRODUCTION
08/19/2024

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 Certification
USCIS or Consular Official's Signature

Date of Signature (mm/dd/yyyy)

Part 9. Applicant's Contact Information, Certification, and Signature
Applicant's Contact Information

Provide your daytime telephone number, mobile telephone number (if any), and email address (if any).
1.

Applicant's Daytime Telephone Number

3.

Applicant's Email Address (if any)

2.

Applicant's Mobile Telephone Number (if any)

Applicant's Certification and Signature
I certify, under penalty of perjury, that I provided or authorized all of the information contained in and submitted with my application,
I read and understand or, if interpreted to me in a language in which I am fluent by the interpreter listed in Part 10., understood, all of
the responses and information contained in, and submitted with, my application, and that all of the responses and information are
complete, true, and correct. Furthermore, I authorize the release of any information from any and all of my records that USCIS may
need to determine my eligibility for an immigration request and to other entities and persons where necessary for the administration
and enforcement of U.S. immigration law.
4.

Applicant's Signature

Form N-565 Edition 04/01/24

Date of Signature (mm/dd/yyyy)

Page 5 of 7

Part 10. Interpreter's Contact Information, Certification, and Signature
Interpreter's Full Name
1.

Interpreter's Family Name (Last Name)

2.

Interpreter's Business or Organization Name

Interpreter's Given Name (First Name)

DRAFT
NOT FOR
PRODUCTION
08/19/2024

Interpreter's Contact Information
3.

Interpreter's Daytime Telephone Number

5.

Interpreter's Email Address (if any)

4.

Interpreter's Mobile Telephone Number (if any)

Interpreter's Certification and Signature

I certify, under penalty of perjury, that I am fluent in English and
, and I have
interpreted every question on the application and Instructions and interpreted the applicant's answers to the questions in that language,
and the applicant informed me that they understood every instruction, question, and answer on the application.
6.

Interpreter's Signature

Date of Signature (mm/dd/yyyy)

Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant
Preparer's Full Name
1.

Preparer's Family Name (Last Name)

2.

Preparer's Business or Organization Name

Preparer's Given Name (First Name)

Preparer's Contact Information
3.

Preparer's Daytime Telephone Number

5.

Preparer's Email Address (if any)

4.

Preparer's Mobile Telephone Number (if any)

Preparer's Certification and Signature
I certify, under penalty of perjury, that I prepared this application for the applicant at their request and with express consent and that
all of the responses and information contained in and submitted with the application are complete, true, and correct and reflects only
information provided by the applicant. The applicant reviewed the responses and information and informed me that they understand
the responses and information in or submitted with the application.
6.

Signature of Preparer

Form N-565 Edition 04/01/24

Date of Signature (mm/dd/yyyy)

Page 6 of 7

Part 12. 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.

Page Number

Part Number

Item Number

4.

Page Number

Part Number

Item Number

5.

Page Number

Part Number

Item Number

6.

Page Number

Part Number

Item Number

Given Name (First Name)

Middle Name

DRAFT
NOT FOR
PRODUCTION
08/19/2024
► A-

Form N-565 Edition 04/01/24

Page 7 of 7