Form N-565 - Application For Replacement Naturalization/citizenship Document Page 3
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7Part 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.
Marriage or divorce on (Attach a copy of marriage or divorce certificate)
(mm/dd/yyyy)
B.
Court Order (Attach a certified copy of the document)
(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.
Court Order (Attach a certified copy of the document)
(mm/dd/yyyy)
B.
State-issued document (For example, birth certificate, certificate recognizing
(mm/dd/yyyy)
the foreign birth, certificate of birth abroad, or other similar records issued
by the child's state of residence.)
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):
Court Order (Attach a certified copy of the document)
A.
B.
Amended birth certificate (Attach a certified copy of the document)
C.
Other official documentation recognizing the new gender by U.S. state, local jurisdiction, or foreign state, such as a
passport or driver's license.
D.
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 06/13/17 N
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