Form N-565 - Application For Replacement Naturalization/citizenship Document Page 7
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7Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if
Other Than the Applicant (continued)
Preparer's Statement
7.
A.
I am not an attorney or accredited representative but have prepared this application on behalf of
the applicant and with the applicant's consent.
B.
I am an attorney or accredited representative and my representation of the applicant in this case
extends
does not extend beyond the preparation of this application.
NOTE: If you are an attorney or accredited representative, you may be obliged to submit a
completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative
with this application.
Preparer's Certification
By my signature, I certify, under penalty of perjury, that I prepared this application at the request of the applicant. The applicant then
reviewed this completed application and informed me that he or she understands all of the information contained in, and submitted
with, his or her application, including the Applicant's Certification, and that all of this information is complete, true, and correct. I
completed this application based only on information that the applicant provided to me or authorized me to obtain or use.
Preparer's Signature
8.
Signature of Preparer
Date of Signature
(mm/dd/yyyy)
Form N-565 06/13/17 N
Page 7 of 7
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