Form N-565, Application for Replacement Naturalization/Citizenship

Page 1 of 9Form N-565 Edition 04/01/24

Application for Replacement

Naturalization/Citizenship Document

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS

Form N-565

OMB No. 1615-0091

Expires 02/28/2027

Select this box if

Form G-28 is

attached

For

USCIS

Use

Only

START HERE - Type or print in black ink.►

Remarks

Relocated

Received

Relocated

Sent

Resubmitted

Applicant

Interviewed

Citizenship Verified by:

Declaration of

Intention Verified by:

To Be Completed by an

Attorney or Accredited

Representative (if any)

Attorney State Bar Number

(if applicable)

Attorney or Accredited Representative

USCIS Online Account Number (if any)

Part 1. Information From Current Certificate or Declaration

1. Your Full Name

Action Block

Fee Stamp

Returned

Family Name (Last Name) Given Name (First Name) Middle Name

Provide your full name exactly as it is printed on the certificate or declaration.

Country of Former Citizenship or Nationality

Certificate or Declaration Number

►

A-

Alien Registration Number (A-Number)

4. 5.

U.S. Citizenship and Immigration Services (USCIS) Office or Name of Court Date (mm/dd/yyyy)

Certificate or Declaration Issuance

Provide information about who issued your last certificate or declaration along with the date it was issued.

Part 2. Current Information About You

Family Name (Last Name)

Your Full Legal Name (Do not provide a nickname)

Given Name (First Name) Middle Name

Date of Birth on Certificate or Declaration2.

(mm/dd/yyyy)

Page 2 of 9Form N-565 Edition 04/01/24

Current Mailing Address

City or Town State ZIP Code

In Care Of Name

Street Number and Name Apt. Flr.Ste.

Province Country

Postal Code

Part 2. Current Information About You (continued)

5. Your Current Marital Status

Single Married WidowedDivorced

4. Has your marital status changed since your last document was issued? NoYes

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.

Marriage Annulled

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

NOTE: If you answered “Yes” to Item Number 6., provide an explanation in Part 12. Additional Information or attach a

separate sheet of paper.

Number

Other Names Used2.

Family Name (Last Name) Given Name (First Name) Middle Name

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.

Part 3. Type of Application

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

New Certificate of CitizenshipA.

New Certificate of NaturalizationB.

New Certificate of Repatriation

New Declaration of Intention

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.

Select all applicable boxes and provide explanations where requested.

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

Basis for My Application

My certificate or declaration was lost, stolen, or destroyed. 2.

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.

Page 3 of 9Form N-565 Edition 04/01/24

My certificate or declaration is mutilated.

My certificate or declaration is incorrect due to a typographical or clerical error by USCIS.

NOTE: If you selected Item Number 3., go to Part 9. and attach the original certificate or declaration.

NOTE: If you selected Item Number 4., go to Part 4. and attach the original certificate or declaration.

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

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

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.

My name has legally changed.5.

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

change.

NOTE: If you selected Item Number 6., go to Part 6. and attach the original certificate and evidence of the date of birth change.

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

gender change.

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.

Provide an explanation.

Part 3. Type of Application (continued)

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

supporting your request.

Part 4. Complete If Applying to Correct Your Document Due to a USCIS Typographical or

Clerical Error

1. What was the typographical or clerical error in your document that needs to be corrected? (select all applicable boxes)

Name Date of Birth OtherGender

NOTE: After completing this section, go to Part 9.

Page 4 of 9Form N-565 Edition 04/01/24

Part 5. Complete If Applying for a New Document Because of a Name Change

My name changed through (select only one box):

Court OrderMarriage, Divorce, or Annulment A. B.

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.

Date of Event (mm/dd/yyyy)

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.

Family Name (Last Name)

My new legal name is:

Given Name (First Name) Middle Name

Part 6. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth

Change

U.S. Government-Issued Document

My date of birth changed through (select all applicable boxes):

A. B.

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.

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).

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

Court Order

Date of Court Order

(mm/dd/yyyy)

Part 7. Complete If Applying for a New Document Because of an Official Change in Gender

Government-Issued Document Reflecting the Gender Change

My gender officially changed through (select all applicable boxes):

A. B.

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.

Court Order

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.

My current gender designation is:

Male Female

Page 5 of 9Form N-565 Edition 04/01/24

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

Name of Foreign Country

2. Information About Foreign Official

Family Name (Last Name) Given Name (First Name) Middle Name

Official Title Name of Government Agency

Provide the following information about the official of a foreign country who has requested this certificate (if known).

3. Foreign Official's Address

City or Town State ZIP Code

Street Number and Name Apt. Flr.Ste.

Province Country Postal Code

Number

USCIS or Consular Official's Certification

Date of Signature (mm/dd/yyyy)

USCIS or Consular Official's Signature

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.

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.

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.

NOTE: Select the box for either Item A. or B. in Item Number 1. If applicable, select the box for Item Number 2.

Applicant's Statement Regarding the Interpreter

Applicant's Statement

Page 6 of 9Form N-565 Edition 04/01/24

The interpreter named in Part 10. read to me every every question and instruction on this application and my answer to

Applicant's Statement Regarding the Preparer

understood everything.

, a language in which I am fluent, and I

every question in

At my request, the preparer named in Part 11.,

prepared this application for me based only upon information I provided or authorized.

Applicant's Contact Information

4.Applicant's Daytime Telephone Number

Applicant's Email Address (if any)

Applicant's Mobile Telephone Number (if any)

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.

Applicant's Certification

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.

Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued)

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.

Date of Signature (mm/dd/yyyy)Applicant's Signature

Applicant's Signature

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

Interpreter's Family Name (Last Name)1.

Provide the following information about the interpreter.

Interpreter's Given Name (First Name)

Interpreter's Business or Organization Name (if any)2.

Interpreter's Full Name

Page 7 of 9Form N-565 Edition 04/01/24

City or Town State ZIP Code

Street Number and Name Apt. Flr.Ste.

Province Country

Postal Code

Interpreter's Mailing Address

Number

Interpreter's Contact Information

Interpreter's Daytime Telephone Number

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 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.

Date of Signature (mm/dd/yyyy)Interpreter's Signature

Interpreter's Signature

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

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.

1. Preparer's Family Name (Last Name) Preparer's Given Name (First Name)

2. Preparer's Business or Organization Name (if any)

Preparer's Full Name

Page 8 of 9Form N-565 Edition 04/01/24

Preparer's Mailing Address

Preparer's Contact Information

Preparer's Daytime Telephone Number

Preparer's Email Address (if any)

Preparer's Mobile Telephone Number (if any)4.

City or Town State ZIP Code

Street Number and Name Apt. Flr.Ste.

Province Country Postal Code

Number

Preparer's Statement

I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with

the applicant's consent.

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.

I am an attorney or accredited representative and my representation of the applicant in this case

does not extend beyond the preparation of this application.extends

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 Certification

Preparer's Signature

Signature of Preparer

Date of Signature (mm/dd/yyyy)

Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if

Other Than the Applicant (continued)

Page 9 of 9Form N-565 Edition 04/01/24

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.

A-Number (if any) ►

A-

Page Number

Part Number Item Number

Family Name (Last Name) Given Name (First Name) Middle Name

B. C.

Page Number

Part Number

Item Number4. B. C.

Page Number

Part Number Item Number

5. B. C.

Page Number

Part Number Item Number

6. B. C.