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N-565, Application for Replacement Naturalization/Citizenship Document (United States)

This form is to apply for a replacement naturalization document of the United States. The form provided here is simply a sample of what the actual Form N-565 looks like.

Department of Homeland Security
U.S Citizenship and Immigration Services

N-565, Application for Replacement Naturalization/Citizenship Document


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For USCIS Use Only

Returned ____________________________

Resubmitted ____________________________

Reloc Sent ____________________________

Reloc Rec'd ____________________________

____ Applicant Interviewed ____________________________

____ Declaration of Intention verified by ____________________________

____ Citizenship verified by ____________________________

Receipt ____________________________

Remarks

Action Block

To Be Completed by Attorney or Representative, if any

____ Fill in box if G-28 is attached to represent the applicant

VOLAG# ____________________________

ATTY State License # ____________________________

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START HERE - Please type or print in black ink.

Part 1. Information about you.

Family Name ____________________________

Given Name ____________________________

Middle Name ____________________________

Address - In care of: ____________________________

Street Number and Name ____________________________

Apt # ____________________________

City or town ____________________________

State or Province ____________________________

Country ____________________________

Zip or Postal Code ____________________________

Date of Birth (mm/dd/yyyy) ____________________________

Country of Birth ____________________________

Certificate Number ____________________________

A # ____________________________

Telephone # (with area/country codes) ____________________________

E-Mail Address (if any) ____________________________

Part 2. Type of application.

1. I hereby apply for: (check one) ____________________________

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.

2. Basis for application: (If you checked other than "e" in Part 1, check one)

a. ____ My certificate is/was lost, stolen or destroyed (attach a copy of the certificate if you have one). Explain when, where and how.

b. ____ My certificate is mutilated (attach the certificate).

c. ____ My name has been changed (attach the certificate).

d. ____ My certificate or declaration is incorrect (attach the documents).

Part 3. Processing information.

Gender ____ Male ____ Female

Height ____________________________

Marital Status ____ Single ____ Married ____ Widowed ____ Divorced

My last certificate or Declaration of Intention was issued to me by:

USCIS Office or Name of Court ____________________________

Date (mm/dd/yyyy) ____________________________

Name in which the document was issued: ____________________________

Other names I have used (if none, so indicate): ____________________________

Since becoming a citizen, have you lost your citizenship in any manner? ____ No ____ Yes (attach an explanation)

Part 4. Complete if applying for a new document because of a name change.

Name changed to present name by: (check one)

____ Marriage or divorce on (month/day/year) ____________________________ (Attach a copy of marriage or divorce certificate).

____ Court Decree (month/day/year) ____________________________ (Attach a copy of the court decree).

Part 5. 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 the documents supporting your request.

Part 6. Complete if applying for a special certificate of recognition as a citizen of the U.S. by the Government of a foreign country.

Name of Foreign Country ____________________________

Information about official of the country who has requested this certificate (if known)

Name ____________________________

Official Title ____________________________

Government Agency ____________________________

Address: Street # and Name ____________________________

Room # ____________________________

City ____________________________

State/Province ____________________________

Country ____________________________

Zip or Postal Code ____________________________

Part 7. Signature.

Read the information on penalties in the instructions before completing this part. If you are going to file this application at an USCIS office in the United States sign below. If you are going to file this application at a USCIS office abroad, sign it in front of a USCIS or Consular Official.

I certify, or if outside the United States, I swear or affirm, under penalty of perjury under the laws of the United States of America, that this application and the evidence submitted with it is all true and correct. I authorize the release of any information from my records which the U.S. Citizenship and Immigration Services needs to determine eligibility for the benefit I am seeking.

Signature ____________________________

Date ____________________________

Signature of USCIS or Consular Official ____________________________

Print Name ____________________________

Date ____________________________

NOTE: If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible for a certificate and this application may be denied.

Part 8. Signature of person preparing form, if other than above.
(Sign below.)

I declare that I prepared this application at the request of the above person and it is based on all information of which I have knowledge.

Signature ____________________________

Print Your Name ____________________________

Date ____________________________

Firm Name and Address ____________________________

Telephone Number (with area code) ____________________________

E-Mail Address (if any) ____________________________


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INSTRUCTIONS FOR FILLING OUT THIS FORM
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Purpose of This Form.

This form is used to apply to the U.S. Citizenship and Immigration Services (USCIS) for a replacement:

• Declaration of Intention, or
• Naturalization Certificate, or
• Certificate of Citizenship, or
• Repatriation Certificate, or to
• Apply for a special certificate of naturalization as a U.S. citizen to be recognized by a foreign country.

NOTE: USCIS is comprised of offices of the former Immigration and Naturalization Service (INS).

Who May File?

You may apply for a replacement:

If you have been issued a Naturalization Certificate, Certificate of Citizenship, Declaration of Intention or Repatriation Certificate which has been lost, mutilated, or destroyed, or;

If your name has been changed by marriage or by court order after the document was issued and you seek a document in the new name.

If you are a naturalized citizen desiring to obtain recognition as a citizen of the United States by a foreign country, you may apply for a special certificate for that purpose.

General Filing Instructions.

Please answer all questions by typing or clearly printing in black ink. Indicate that an item is not applicable with "N/A." If an answer is "none," so state. If you need extra space to answer any item, attach a sheet of paper with your name and your A#, if any, and indicate the number of the item.

Every application must be properly signed and filed with the correct fee. If you are under 14 years of age, your parent or guardian may sign the application in your behalf.

Initial Evidence Requirements.

You must file your application with the following evidence:

You must submit two standard passport-style photographs in color of yourself taken within 30 days of this application. These photos must be glossy, unretouched and unmounted, and have a white background. The dimension of your full frontal facial position should be about 1 inch from your chin to the top of your hair. Using pencil or felt pen, lightly print your name and A# if any, on the back of each photo. This requirement may be waived by USCIS if you can establish that you are confined because of age or physical infirmity.

If you are applying for replacement of a mutilated document, you must attach the mutilated document. If you are applying for a new document because your name has been changed, you must submit the original USCIS (or former INS) document and a copy of the marriage certificate or court order showing the name change.

If you are applying for a special certificate of naturalization, you must attach a copy of your naturalization certificate.

Copies.

If these instructions state that a copy of a document may be filed with this application, and you choose to send us the original, we may keep that original for our records.

Where to File.

File this application at the local USCIS office having jurisdiction over your place of residence.

What Is the Fee?

The fee for this petition is $220.00, except there is no fee if you check block 2 (d) of Part 2 of the form.

The fee must be submitted in the exact amount. It cannot be refunded. Do not mail cash.

All checks and money orders must be drawn on a bank or other institution located in the United States and must be payable in United States currency. The check or money order should be made payable to the Department of Homeland Security, except that:

If you live in Guam, and are filing this application in Guam, make your check or money order payable to the "Treasurer, Guam."

If you live in the U.S. Virgin Islands, and are filing this application in the U.S. Virgin Islands, make your check or money order payable to the "Commissioner of Finance of the Virgin Islands."

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