Form N-565 - Application For Replacement Naturalization/citizenship Document
Download a blank fillable Form N-565 - Application For Replacement Naturalization/citizenship Document in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form N-565 - Application For Replacement Naturalization/citizenship Document with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2OMB No. 1615-0091; Expires 07/31/2012
Form N-565, Application for Replacement
Department of Homeland Security
Naturalization/Citizenship Document
U.S. Citizenship and Immigration Services
START HERE - Please type or print in black ink
For USCIS Use Only
Receipt
Part 1.
Information about you.
Returned
Family Name
Given Name
Middle Name
Address - In care of:
Resubmitted
Street Number and Name
Apt. Number
City or Town
State or Province
Country
Zip or Postal Code
Reloc Sent
Date of Birth (mm/dd/yyyy)
Country of Birth
Certificate Number
A-Number
Reloc Rec'd
Telephone Number (with area/country codes)
E-Mail Address (if any)
Part 2. Type of application
1. I hereby apply for: (check one)
Applicant
a.
New Certificate of Citizenship
Interviewed
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
Declaration of Intention verified by
foreign country. (Skip Number 2 and go to Part 3)
2. Basis for application: (Refer to the instructions for additional information.)
Citizenship verified by
a.
My certificate is/was lost, stolen or destroyed (attach a copy of the certificate if you
have one.) Explain when, where and how.
Remarks
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 document(s)).
Part 3. Processing information
Marital
Gender
Male
Height
Single
Widowed
Status
Female
Married
Divorced
My last certificate or Declaration of Intention was issued to me by:
Action Block
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)
To Be Completed by
Part 4. Complete if applying for a new document because of a name
Attorney or Representative, if any.
change
Fill in box if Form G-28 is attached
Name changed to present name by: (check one)
to represent the applicant.
Marriage or divorce on (month/day/year)
VOLAG#
(Attach a copy of marriage or divorce certificate)
ATTY State License #
Court Decree (month/day/year)
(Attach a copy of the court decree)
Form N-565 (Rev. 07/08/11) Y
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal