N-565
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| START HERE - Type or print in black ink. |
| Part 1. Information From Current Certificate or Declaration |
| 1. | Your Full Name |
| Provide your full name exactly as it is printed on the certificate or declaration. |
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| 2. | Date of Birth on Certificate or Declaration
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3. | Country of Former Citizenship or Nationality
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| 4. | Certificate or Declaration Number
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5. | Alien Registration Number (A-Number)
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| 6. | Certificate or Declaration Issuance |
| Provide information about who issued your last certificate or declaration along with the date it was issued. |
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| Part 2. Current Information About You |
| 1. | Your Full legal Name ( Do not provide a nickname) |
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| Form N-565 Edition 04/01/24 | Page 1 of 9 |
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| Part 2. Current Information About You (continued) |
| 2. | Other Names Used |
| Provide all other names you have ever used, including aliases, maiden name, and nicknames. If you need extra space to complete this section, use the space provided in Part 12. Additional Information. |
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| 3. |
Current Mailling Address
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| 4. | Has your marital status changed since your last document was issued? |
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| NOTE: If you answered “Yes” to Item Number 4., provide your current marital status in Item Number 5. and attach a copy of your marriage certificate, annulment decree, divorce decree, or spouse's death certificate. |
| 5. | Your Current Marital Status |
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| 6. | Since becoming a U.S. citizen, have you lost or renounced your U.S. citizenship in any manner? |
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| NOTE: If you answered “Yes” to Item Number 6., provide an explanation in Part 12. Additional Information or attach a separate sheet of paper. |
| Part 3. Type of Application |
| 1. | I am applying for a (select only one box): |
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| NOTE: If you selected Item E., skip the Basis for My Application section below and go to Part 8 |
| Basis for My Application |
| Select all applicable boxes and provide explanations where requested. |
| 2. | A. |
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| B. |
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| NOTE: If you selected Item A. in Item Number 2., go to Part 9. and attach a copy of the certificate or declaration (if available), police report, and/or sworn statement |
| Form N-565 Edition 04/01/24 | Page 2 of 9 |
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| Part 3. Type of Application (continued) |
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| 6. | My date of birth has legally changed through a court order or U.S. Government-issued document, and I am applying for a replacement Certificate of Citizenship. |
| NOTE: If you select Item Number 6., go to Part 6. and attach the original certificate and evidence of the date of birth chagne. |
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| 8. | A. |
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| NOTE: If you selected Item A. in Item Number 8., go to Part 9. and attach the original certificate or declaration and any evidence documents. |
| Part 4. Complete If Applying to Correct Your Document Due to a USCIS Typographical or Clerical Error |
| NOTE: After completing this section, go to Part 9. |
| 1. | What was the typographical or clerical error in your document that needs to be corrected? (select all applicable boxes) |
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| 2. |
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| Form N-565 Edition 04/01/24 | Page 3 of 9 |
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| Part 5. Complete If Applying for a New Document Because of a Name Change |
| NOTE: After completing this section, go to Part 9. If you are applying to correct your document due to a USCIS error, use Part 4. |
| 1. | My name changed through (select only one box): |
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| NOTE: If you selected Item A., attach a copy of your marriage certificate, annulment decree, or divorce decree. If you selected Item B., attach a copy of either the original or certified court document |
| 2. | My new legal name is: |
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| Part 6. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth Change |
| NOTE: After completing this section, go to Part 9. If you are applying to correct your document due to a USCIS error, use Part 4 |
| 1. | My date of birth changed through (select all applicable boxes): |
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| NOTE: If you selected Item A., attach a copy of either the original or certified court document. If you selected Item B., attach a copy of the document (for example, birth certificate, certificate recognizing the foreign birth, certificate of birth abroad, or other similar vital records issued by the U.S. state where the child resided when the document was issued). |
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My new date of birth is (as shown in the court order or U.S. Government-issued document): (mm/dd/yyyy)
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| Part 7. Complete If Applying for a New Document Because of an Official Change in Gender |
| NOTE: After completing this section, go to Part 9. If you are applying to correct your document due to a USCIS error, use Part 4. |
| 1. | My gender officially changed through (select all applicable boxes): |
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| NOTE: If you selected Item A., attach a copy of either the original or certified court document. If you selected Item B., attach a copy of the document. If you selected Item C., attach the certification letter |
| 2. | My current gender designation is: |
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| Form N-565 Edition 04/01/24 | Page 4 of 9 |
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| Part 8. Complete If Applying for a Special Certificate of Recognition as a Citizen of the United States to the Government of a Foreign Country |
| 1. |
Name of Foreign Country
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| 2. | Information About Foreign Official |
| Provide the following information about the official of a foreign country who has requested this certificate (if known). |
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| 3. |
Foreign Official's Address
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| USCIS or Consular Official's Certification |
| NOTE: The USCIS or consular official's certification will be completed after USCIS adjudicates your Form N-565, if it is approved. You do not need to obtain this signature before filing this application |
| 4. | USCIS or Consular Official's Certification |
USCIS or Consular Official's Signature
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| Part 9. Applicant's Statement, Contact Information, Certification, and Signature |
| NOTE: Read the Penalties section of the Form N-565 Instructions before completing this section. |
| By signing this application, you state under penalty of perjury (28 U.S.C. section 1746) that all information and documentation submitted with this application is complete, true, and correct. You also authorize the release of any information from your records that USCIS may need to determine your eligibility for the immigration benefit you are seeking and consent to USCIS verifying such information. |
| The Department of Homeland Security (DHS) has the authority to verify any information you submit to establish eligibility for the
immigration benefit you are seeking at any time. USCIS' legal authority to verify this information is in 8 U.S.C. sections 1103 and 1454 and 8 CFR parts 103 and 338. To ensure compliance with applicable laws and authorities, USCIS may verify information before or after your case is decided. |
| 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 |
| A. |
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| Form N-565 Edition 04/01/24 | Page 5 of 9 |
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| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued) |
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| 2. | Applicant's Statement Regarding the Preparer |
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| Applicant's Contact Information |
| 3. |
Applicant's Daytime Telephone Number
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4. |
Applicant's Mobile Telephone Number (if any)
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| 5. |
Applicant's Email Address (if any)
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| 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 and all of my records that USCIS may need to determine my eligibility for the immigration benefit that I seek. |
| I furthermore 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 law. |
| I understand that USCIS may require me to appear for an appointment to take my biometrics and, if I am required to appear, I will be required to sign an oath reaffirming that: |
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| 3) |
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| I certify, under penalty of perjury, that I provided or authorized all of the information in my application, I understand all of the information contained in, and submitted with, my application, and that all of this information is complete, true, and correct. |
| Applicant's Signature |
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| NOTE TO ALL APPLICANTS: If you do not completely fill out this application or fail to submit required documents listed in the Instructions, USCIS may deny your application. |
| Part 10. Interpreter's Contact Information, Certification, and Signature |
| Provide the following information about the interpreter. |
| Interpreter's Full Name |
| 1. |
Interpreter's Family Name (Last Name)
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Interpreter's Given Name (First Name)
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| 2. |
Interpreter's Business or Organization Name (if any)
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| Form N-565 Edition 04/01/24 | Page 6 of 9 |
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| Part 10. Interpreter's Contact Information, Certification, and Signature (continued) |
| Interpreter's Mailing Address |
| 3. |
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| Interpreter's Contact Information |
| 4. |
Interpreter's Daytime Telephone Number
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5. |
Interpreter's Mobile Telephone Number (if any)
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| 6. |
Interpreter's Email Address (if any)
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| Interpreter's Certification |
| I certify, under penalty of perjury, that: |
| I am fluent in English and , which is the same language specified in Part 9., |
| Item B. in Item Number 1., and I have read to this applicant in the identified language every question and instruction on this application and his or her answer to every question. The applicant informed me that he or she understands every instruction, question, and answer on the application, including the Applicant's Certification, and has verified the accuracy of every answer. |
| Interpreter's Signature |
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant |
| Provide the following information about the preparer |
| Preparer's Full Name |
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Preparer's Family Name (Last Name)
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Preparer's Given Name (First Name)
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| 2. |
Preparer's Business or Organization Name (if any)
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| Form N-565 Edition 04/01/24 | Page 7 of 9 |
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant (continued) |
| Preparer's Mailing Address |
| 3. |
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| Preparer's Contact Information |
| 4. |
Preparer's Daytime Telephone Number
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5. |
Preparer's Mobile Telephone Number (if any)
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| 6. |
Preparer's Email Address (if any)
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| Preparer's Statement |
| 7. | A. |
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| B. |
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| 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
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| Form N-565 Edition 04/01/24 | Page 8 of 9 |
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| Part 12. Additional Information |
| If you need extra space to provide any additional information within this application, use the space below. If you need more space than what is provided, you may make copies of this page to complete and file with this application or attach a separate sheet of paper. Type or print your name and A-Number (if any) at the top of each sheet; indicate the Page Number, Part Number, and Item Number to which your answer refers; and sign and date each sheet. |
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A-Number (if any)
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| D. |
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| Form N-565 Edition 04/01/24 | Page 9 of 9 |
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