Form N-565 - Application For Replacement Naturalization/citizenship Document Page 2

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Part 5. 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 the documents supporting your request.

Part 6. Complete if applying for a special certificate of recognition as a citizen of the U.S. by the

government of a foreign country

Name of Foreign Country

Information about official of the country who has requested this certificate (if known)

Name

Official Title

Government Agency:

Suite Number

Address: Street Number and Name

City

State/Province

Country

Zip or Postal Code

Part 7. Signature

Read the information on penalties in the instructions before completing this part. If you are going to file this

application at a USCIS office in the United States sign below. If you are going to file this application at a USCIS

office abroad, sign it in front of a USCIS or Consular Official.

I certify, or if outside the United States, I swear or affirm, under penalty of perjury under the laws of the United States of America, that this application

and the evidence submitted with it is all true and correct. I authorize the release of any information from my records which U.S. Citizenship and

Immigration Services needs to determine eligibility for the benefit I am seeking.

Signature

Date (mm/dd/yyyy)

Print Your Name

Date (mm/dd/yyyy)

Signature of USCIS

or Consular Official

NOTE:

If you do not completely fill out this form or fail to submit required documents listed in the instructions, you may not be found eligible

for a certificate and this application may be denied.

Part 8. Signature of person preparing form, if other than the applicant