Form N-565 - Application For Replacement Naturalization/citizenship Document Page 4
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7Part 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
I can read and understand English, and I have read and understand every question and instruction on this application and
A.
my answer to every question.
B.
The interpreter named in Part 10. read to me every question and instruction on this application and my answer to every
question in
, a language in which I am fluent, and I
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.
Applicant's Contact Information
3.
Applicant's Daytime Telephone Number
4.
Applicant's Mobile Telephone Number (if any)
5.
Applicant's Email Address (if any)
Applicant's Certification
Copies of any documents I have submitted are exact photocopies of unaltered, original documents, and I understand that USCIS may
require that I submit original documents to USCIS at a later date. Furthermore, I authorize the release of any information from any of
my records that USCIS may need to determine my eligibility for the immigration benefit I seek.
I further authorize release of information contained in this application, in supporting documents, and in my USCIS records to other
entities and persons where necessary for the administration and enforcement of U.S. immigration laws.
Form N-565 06/13/17 N
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