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TABLE OF CHANGES – FORM

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

OMB Number: 1615-0091

08/19/2024

Reason for Revision: REV

Project Phase: 30 Day

Legend for Proposed Text:

• Black font = Current text

• Red font = Changes

Expires 02/28/2027

Edition Date: 04/01/2024

Current Page Number and Section	Current Text	Proposed Text
Page 1, To Be Completed by an Attorney or Accredited Representative (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) [new]	[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) START HERE - Type or print in black ink.
Page 1, Part 1. Information From Current Certificate or Declaration	[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. Date of Birth on certificate or declaration (mm/dd/yyyy) [new] 3. Country of Former Citizenship or Nationality 4. Certificate or Declaration Number 5. Alien Registration Number (A-Number) 6. 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)	[Page 1] Part 1. Information From Current Certificate or Declaration [no change] 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) 7. Certificate or Declaration Issuance Provide information about who issued your last certificate or declaration along with the date it was issued. [no change]
Page 1, Part 2. Current Information About You	[Page 2] Part 2. Current Information About You 1. Your Full Legal Name (Do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name 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) [x2] Given Name (First Name) [x2] Middle Name [x2] [Page 2] 3. Current 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 12. Additional Information or attach a separate sheet of paper.	[Page 2] Part 2. Current Information About You 1. Your Full Legal Name (Do not provide a nickname) Family Name (Last Name) Given Name (First Name) Middle Name (if applicable) [no change] Family Name (Last Name) [x2] Given Name (First Name) [x2] Middle Name (if applicable) [x2] 3. Current Mailing Address In Care Of Name (if any) Street Number and Name Apt./Ste./Flr. Number City or Town State ZIP Code Province Postal Code Country [deleted] 4. Your Current Marital Status Single Married Divorced Widowed Marriage Annulled 5. 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.
Page 3, Part 3. Type of Application	[Page 3] Part 3. 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 8. 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 9. 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 9. 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 4. and attach the original certificate or declaration. 5. My name has legally changed. NOTE: If you selected Item Number 5., go to Part 5. 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 6. and attach the original certificate 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 7. 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 9. and attach the original certificate or declaration and any evidence documents.	[Page 3] Part 3. Type of Application I am applying for a (select only one box): 1.a. New Certificate of Citizenship 1.b. New Certificate of Naturalization 1.c. New Certificate of Repatriation 1.d. New Declaration of Intention 1.e. Special Certificate of Naturalization to Obtain Recognition of My U.S. Citizenship by a Foreign Country NOTE: If you selected Item Number 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. [Fillable field] 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. 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. 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. [Fillable field] NOTE: If you selected Item Number 2.g., go to Part 9. and attach the original certificate or declaration and any evidence documents.
Page 4, Part 5. Complete If Applying for a New Document Because of a Name Change	[Page 4] 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. 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 4] 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 Date of Event (mm/dd/yyyy) 1.b. Court Order Date of Court Order (mm/dd/yyyy) 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. [deleted]
Page 4, Part 6. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth Change	[Page 4] 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. 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 4] 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). [no change]
Page 5, Part 7. Complete If Applying for a New Document Because of an Official Change in Gender	[Page 5] Part 7. Complete If Applying for a New Document Because of an Official Change in 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. My gender officially changed through (select all applicable boxes): A. Court Order 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 5] 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 [deleted]
Page 5, 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	[Page 5] 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) Given name (First Name) Middle Name Official Title …	[Page 5] 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 [no change] Family Name (Last Name) Given name (First Name) Middle Name (if applicable) [no change] …
Page 6, Part 9. Applicant’s Statement, Contact Information, Certification, and Signature	[Page 6] Part 9. 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 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 Filed], prepared this application for me based only upon information I provided or authorized. Applicant’s Contact Information [new] 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 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 may require me to appear for an appointment to take my biometrics and, if I am required to appear, 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. [Page 7] 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 6] Part 9. Applicant’s Contact Information, Certification, and Signature [deleted] 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 2. Applicant’s Mobile Telephone Number (if any) 3. Applicant’s Email Address (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. [deleted] 4. Applicant’s Signature Date of Signature (mm/dd/yyyy) [deleted]
Page 7, Part 10. Interpreter’s Contact Information, Certification, and Signature	[Page 7] 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. 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 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 7] Part 10. Interpreter’s Contact Information, Certification, and Signature [deleted] Interpreter’s Full Name 1. Interpreter’s Family Name (Last Name) Interpreter’s Given Name (First Name) 2. Interpreter’s Business or Organization Name [deleted] Interpreter’s Contact Information 3. Interpreter’s Daytime Telephone Number 4. Interpreter’s Mobile Telephone Number (if any) 5. Interpreter’s Email Address (if any) Interpreter’s Certification and Signature I certify, under penalty of perjury, that I am fluent in English and [Fillable Field], 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. [deleted] 6. Interpreter’s Signature Date of Signature (mm/dd/yyyy)
Page 8, Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant	[Page 8] 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. 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)	[Page 8] Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant [deleted] Preparer’s Full Name 1. Preparer’s Family Name (Last Name) Preparer’s Given Name (First Name) 2. Preparer’s Business or Organization Name Preparer’s Contact Information 3. Preparer’s Daytime Telephone Number 4. Preparer’s Mobile Telephone Number (if any) 5. Preparer’s Email Address (if any) [deleted] 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. [deleted] 6. Preparer’s Signature Date of Signature (mm/dd/yyyy)
Page 9, Part 12. Additional Information	[Page 9] … 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]	[Page 9] … 3. Page Number Part Number Item Number [Fillable field] 4. Page Number Part Number Item Number [Fillable field] 5. Page Number Part Number Item Number [Fillable field] 6. Page Number Part Number Item Number [Fillable field]

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