Application for Replacement Naturalization/Citizenship Document Department of Homeland Security U.S. Citizenship and Immigration Services Returned Resubmitted Relocated Sent USCIS Form N-565 OMB No. 1615-0091 Expires 05/31/2017 Fee Stamp Action Block For Relocated Received USCIS Use Applicant Interviewed Only Declaration of Intention Verified by: Citizenship Verified by: Remarks: To be completed by an attorney or BIA-accredited representative (if any) Select this box if Form G-28 is attached to represent the applicant. Attorney State Bar Number (if applicable) Attorney or Accredited Representative USCIS Online Account Number (if any) START HERE - Type or print in black ink. Part 1. Information About You 1. Full Legal Name Family Name (Last Name) Given Name (First Name) Middle Name 2. Date of Birth (mm/dd/yyyy) 3. Country of Birth 4. Certificate Number 5. Alien Registration Number (A-Number) A6. Mailing Address In Care Of Name Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Province Postal Code Country Form N-565 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 Part 2. Type of Application 1. I hereby apply for (select only one box): A. B. C. 2. New Certificate of Citizenship New Certificate of Naturalization New Certificate of Repatriation D. E. New Declaration of Intention Special Certificate of Naturalization to obtain recognition of my U.S. citizenship by a foreign country. (Skip Item Number 2. and complete Part 3., Part 8., and Part 9.) Basis for application (Select all applicable boxes): A. My certificate was lost, stolen, or destroyed. Explain when, where, and how. (Complete Part 3. and Part 9., and attach a copy of the certificate (if any), police report, or sworn statement.) B. C. D. E. My certificate is mutilated. (Complete Part 3., Part 9., and attach the certificate.) My certification or declaration is incorrect due to typographical/clerical error. (Complete Part 3., Part 4., and Part 9., and attach the documents.) My name has legally changed. (Complete Part 3., Part 5., and Part 9., and attach the certificate and documents.) My date of birth has legally changed due to a court order or other state-issued documents. NOTE: Only applicants applying for a replacement Certificate of Citizenship may select this option. (Complete Part 3., Part 6., and Part 9., and attach the certificate and documents.) My gender has legally changed. (Complete Part 3., Part 7., and Part 9., and attach the certificate and documents.) Other: Explain (Complete Part 3., Part 4., and Part 9., and attach the documents.) F. G. Part 3. Processing Information 1. Gender Male Female 2. Height Feet Inches 3. Marital Status Single Married Divorced Widowed My last certificate or Declaration of Intention was issued to me by: 4. USCIS Office or Name of Court 5. Date (mm/dd/yyyy) 6. Name in Which the Document Was Issued 7. Other Names I Have Used (if none, type or print "None") Family Name (Last Name) Given Name (First Name) Middle Name 8. Since becoming a citizen, have you lost or renounced your citizenship in any manner? Yes (attach an explanation) No Form N-565 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 Part 4. 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 any documents supporting your request. Part 5. Complete If Applying for a New Document Because of a Name Change Name changed because of (select only one box): A. B. Marriage or divorce on (Attach a copy of marriage or divorce certificate) Court Order (Attach a certified copy of the document) (mm/dd/yyyy) (mm/dd/yyyy) Part 6. Complete If Applying for a New Certificate of Citizenship Because of a Date of Birth Change Date of birth changed by: A. B. Court Order (Attach a certified copy of the document) State-issued document (For example, birth certificate, certificate recognizing the foreign birth, certificate of birth abroad, or other similar records issued by the child's state of residence.) (mm/dd/yyyy) (mm/dd/yyyy) Part 7. Complete If Applying for a New Document Because of a Change in Gender Evidence of official recognition of gender change recognized by (select all applicable boxes): A. B. C. D. Court Order (Attach a certified copy of the document) Amended birth certificate (Attach a certified copy of the document) Other official documentation recognizing the new gender by U.S. state, local jurisdiction, or foreign state, such as a passport or driver's license. Medical certification by a licensed physician (doctor of medicine (M.D.) or doctor of osteopathy (D.O.) Part 8. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States by the Government of a Foreign Country 1. Name of Foreign Country Information about official of the country who has requested this certificate (if known) 2. Family Name (Last Name) Given Name (First Name) Middle Name Official Title Name of Government Agency Form N-565 12/23/16 N American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 Part 8. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States by the Government of a Foreign Country (continued) 3. Address of Foreign Official Street Number and Name Apt. Ste. Flr. City or Town State ZIP Code Province Postal Code Country USCIS or Consular Official's Certification 4. USCIS or Consular Official's Signature Date of Signature (mm/dd/yyyy) Part 9. Applicant's Statement, Contact Information, Certification, and Signature NOTE: Read the Penalties section of the Form N-565 Instructions before completing this part. 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. B. 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. The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every question in understood everything. 2. Applicant's Statement Regarding the Preparer At my request, the preparer named in Part 11., prepared this application for me based only upon information I provided or authorized. , , a language in which I am fluent, and I Applicant's Contact Information 3. Applicant's Daytime Telephone Numb