Form N-565 - Application For Replacement Naturalization/citizenship Document Page 2
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7Part 2. Type of Application
1. I hereby apply for (select only one box):
A.
New Certificate of Citizenship
New Declaration of Intention
D.
B.
New Certificate of Naturalization
Special Certificate of Naturalization to obtain recognition of my
E.
U.S. citizenship by a foreign country. (Skip Item Number 2. and
New Certificate of Repatriation
C.
complete Part 3., Part 8., and Part 9.)
2. 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.
My certificate is mutilated. (Complete Part 3., Part 9., and attach the certificate.)
C.
My certification or declaration is incorrect due to typographical/clerical error. (Complete Part 3., Part 4., and Part 9.,
and attach the documents.)
D.
My name has legally changed. (Complete Part 3., Part 5., and Part 9., and attach the certificate and documents.)
E.
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.)
F.
My gender has legally changed. (Complete Part 3., Part 7., and Part 9., and attach the certificate and documents.)
G.
Other: Explain (Complete Part 3., Part 4., and Part 9., and attach the documents.)
Part 3. Processing Information
1.
Gender
2.
Height
3.
Marital Status
Male
Female
Feet
Inches
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 06/13/17 N
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