Form N-565 - Application For Replacement Naturalization/citizenship Document

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Application for Replacement
Naturalization/Citizenship Document
USCIS
Form N-565
Department of Homeland Security
OMB No. 1615-0091
U.S. Citizenship and Immigration Services
Expires 06/30/2019
Action Block
Fee Stamp
Returned
Resubmitted
Relocated Sent
For
Relocated Received
USCIS
Use
Remarks:
Applicant Interviewed
Only
Declaration of Intention Verified by:
Citizenship Verified by:
To be completed
Select this box if
Attorney State Bar Number
Attorney or Accredited Representative
by an attorney or
Form G-28 is
(if applicable)
USCIS Online Account Number (if any)
BIA-accredited
attached to represent
the applicant.
representative (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)
A-
6. 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 06/13/17 N
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