Application for Replacement Naturalization/Citizenship DocumentFile Online

• Legal Form Number: N-565
• Section: Citizenship and Immigration Services (United States of America)
• Issuer: Citizenship and Immigration Services (United States of America)

Application for Replacement

Naturalization/Citizenship Document

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form N-565 06/13/17 N

USCIS

Form N-565

OMB No. 1615-0091

Expires 06/30/2019

Page 1 of 7

For

USCIS

Use

Only

Part 1. Information About You

3. Country of Birth 2. Date of Birth (mm/dd/yyyy)

4. Certificate Number

6. Mailing Address

City or Town State ZIP Code

In Care Of Name

Street Number and Name Apt. Flr.Ste.

Family Name (Last Name)

1. Full Legal Name Given Name (First Name) Middle Name

START HERE - Type or print in black ink.►

Remarks:

Action Block

Relocated Received

Relocated Sent

Fee Stamp

Resubmitted

Returned

Applicant Interviewed

Citizenship Verified by:

Declaration of Intention Verified by:

►A-

5. Alien Registration Number (A-Number)

Province Country Postal Code

To be completed

by an attorney or

BIA-accredited

representative (if any)

Select this box if

Form G-28 is

attached to represent

the applicant.

Attorney State Bar Number

(if applicable) Attorney or Accredited Representative

USCIS Online Account Number (if any)