Form N-565, Application for Replacement Naturalization/Citizenship Document Instructions
This form contains 179 fields organized into 43 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Information | ||
| Part 12. Additional Information. 3. A. Enter Page Number | Text |
Enter the page number of the form where additional information is being referenced.
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| Part 12. Additional Information. 3. B. Enter Part Number | Text |
Enter the part number of the form where additional information is being referenced.
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| Part 12. Additional Information. 3. C. Enter Item Number | Text |
Enter the item number of the form where additional information is being referenced.
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| Part 12. Additional Information. 3. D. Enter Additional Information | Text |
Provide any additional information that is relevant to the application and not covered in other sections.
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| Part 12. Additional Information. 4. D. Enter Additional Information | Text |
Use this field to enter any additional information related to your application. If more space is needed, you may attach additional sheets.
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| Part 12. Additional Information. 5. D. Enter Additional Information | Text |
Use this field to enter any additional information related to your application. If more space is needed, you may attach additional sheets.
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| Part 12. Additional Information. 6. D. Enter Additional Information | Text |
Use this field to enter any additional information related to your application. If more space is needed, you may attach additional sheets.
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| Part 12. Additional Information. 5. C. Enter Item Number | Text |
Enter the item number related to the additional information you are providing. This helps specify which part of the form your additional information pertains to.
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| Part 12. Additional Information. 6. A. Enter Page Number | Text |
Enter the page number of the form where the additional information you are providing is relevant. This helps in locating the context of your additional details.
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| Part 12. Additional Information. 6. B. Enter Part Number | Text |
Enter the part number of the form where the additional information you are providing is relevant. This helps in identifying the specific section of the form your additional details relate to.
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| Part 12. Additional Information. 6. C. Enter Item Number | Text |
Enter the item number of the form where the additional information you are providing is relevant. This helps in pinpointing the exact item your additional details pertain to.
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| Applicant Contact Information | ||
| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). Applicant's Contact Information. 4. Enter Applicant's Mobile Telephone Number, if any | Text |
Enter the applicant's mobile telephone number, if available. This should be a 10-digit number.
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| Applicant Signature | ||
| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). Applicant's Signature. 6. Signature of Applicant. This form can not be signed electronically. The name of the applicant can not be typewritten into this space. Print and sign | Text |
Provide the applicant's handwritten signature. This form cannot be signed electronically, and the name cannot be typewritten.
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| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). Applicant's Signature. 6. Date of Signature (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date when the applicant signs the form. Use the format MM/DD/YYYY.
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| Applicant's Statement | ||
| Part 9. Applicant's Statement, Contact Information, Certification, and Signature. 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. Select this box for: A. I can read and understand English, and I have read and understand every question and instruction on this application and my answer to every question | CheckBox |
Select this checkbox if you can read and understand English and have read and understood every question and instruction on this application.
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| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). 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. Select this box for: 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 | CheckBox |
Select this checkbox if the interpreter named in Part 10 read to you every question and instruction on this application in a language you understand.
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| Application Basis | ||
| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. 2. A. Select My certificate or declaration was lost, stolen, or destroyed | CheckBox |
Select this option if your certificate or declaration was lost, stolen, or destroyed.
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| Part 3. Type of Application. Basis for My Application. 2. B. Provide an explanation of when, where, and how this happened. Enter Explanation | Text |
Provide an explanation of when, where, and how your certificate or declaration was lost, stolen, or destroyed. Maximum length is 250 characters.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. Select: 3. My certificate or declaration is mutilated | CheckBox |
Select this option if your certificate or declaration is mutilated.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. Select: 4. My certificate or declaration is incorrect due to a typographical or clerical error by U S C I S | CheckBox |
Select this option if your certificate or declaration is incorrect due to a typographical or clerical error by USCIS.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. Select: 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 | CheckBox |
Select this checkbox if your date of birth has legally changed through a court order or U.S. Government-issued document, and you are applying for a replacement Certificate of Citizenship.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. Select: 8. A. My reason for applying for a new document is not listed above | CheckBox |
Select this checkbox if your reason for applying for a new document is not listed among the provided options.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. Select: 7. I am seeking to change the gender listed on my document | CheckBox |
Select this checkbox if you are seeking to change the gender listed on your citizenship or naturalization document.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. 8. B. Provide an explanation. Enter Explanation | Text |
Provide an explanation for your reason to apply for a new document if it is not listed among the provided options.
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| Part 3. Type of Application. Basis for My Application. Select all applicable boxes and provide explanations where requested. Select: 5. My name has legally changed | CheckBox |
Select this checkbox if your name has legally changed and you are applying for a replacement Certificate of Citizenship.
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| Application Type | ||
| Part 3. Type of Application. 1. I am applying for a (select only one box). Select: A. New Certificate of Citizenship | CheckBox |
Select this option if you are applying for a new Certificate of Citizenship.
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| Part 3. Type of Application. 1. I am applying for a (select only one box). Select B. New Certificate of Naturalization | CheckBox |
Select this option if you are applying for a new Certificate of Naturalization.
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| Part 3. Type of Application. 1. I am applying for a (select only one box). Select: C. New Certificate of Repatriation | CheckBox |
Select this option if you are applying for a new Certificate of Repatriation.
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| Part 3. Type of Application. 1. I am applying for a (select only one box). Select: D. New Declaration of Intention | CheckBox |
Select this option if you are applying for a new Declaration of Intention.
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| Part 3. Type of Application. 1. I am applying for a (select only one box). Select E. Special Certificate of Naturalization to Obtain Recognition of My U.S. Citizenship by a Foreign Country | CheckBox |
Select this option if you are applying for a Special Certificate of Naturalization to obtain recognition of your U.S. citizenship by a foreign country.
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| Attorney Representation | ||
| To Be Completed by an Attorney or Accredited Representative, if any. Select this box if Form G-28 is attached | CheckBox |
Check this box if you are represented by an attorney or accredited representative and have attached Form G-28 to this application.
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| To Be Completed by an Attorney or Accredited Representative, if any. Enter Attorney State Bar Number, if applicable | Text |
Enter the state bar number of your attorney if you are represented by one. This is applicable only if an attorney is involved in your application process.
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| To Be Completed by an Attorney or Accredited Representative, if any. Enter Attorney or Accredited Representative U S C I S Online Account Number, if any | Text |
Enter the U.S. Citizenship and Immigration Services (USCIS) Online Account Number of your attorney or accredited representative, if applicable. This number can be up to 12 characters long.
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| Barcode Information | ||
| PDF417BarCode1 | Text |
This field contains a PDF417 barcode with encoded information about the form.
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| PDF417BarCode1 | Text |
This field contains a PDF417 barcode related to the form N-565. It is automatically generated and does not require user input.
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| PDF417BarCode1 | Text |
This field contains a PDF417 barcode related to the form. No input is required.
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| Certificate Information | ||
| Part 1. Information From Current Certificate or Declaration. 6. Certificate or Declaration Issuance. Provide information about who issued your last certificate or declaration along with the date it was issued. Date (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date your last certificate or declaration was issued. Use the format MM/DD/YYYY.
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| Part 1. Information From Current Certificate or Declaration. 2. Date of Birth on Certificate or Declaration. Enter Date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter your date of birth as it appears on your certificate or declaration. Use the format MM/DD/YYYY.
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| Citizenship Status | ||
| Part 2. Current Information About You. 6. Since becoming a U.S. citizen, have you lost or renounced your U.S. citizenship in any manner? Select No | CheckBox |
Select 'No' if you have not lost or renounced your U.S. citizenship in any manner since becoming a U.S. citizen.
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| Part 2. Current Information About You. 6. Since becoming a U.S. citizen, have you lost or renounced your U.S. citizenship in any manner? Select Yes | CheckBox |
Select 'Yes' if you have lost or renounced your U.S. citizenship in any manner since becoming a U.S. citizen.
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| Contact Information | ||
| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). Applicant's Contact Information. 5. Enter Applicant's Email Address, if any | Text |
Enter your email address, if you have one.
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| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). Applicant's Contact Information. 3. Enter Applicant's Daytime Telephone Number | Text |
Enter your daytime telephone number. The number should be 10 digits long.
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| Current Gender Designation | ||
| Part 7. Complete If Applying for a New Document Because of an Official Change in Gender. 2. My current gender designation is. Select Male | CheckBox |
Select this checkbox if your current gender designation is Male.
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| Part 7. Complete If Applying for a New Document Because of an Official Change in Gender. 2. My current gender designation is. Select Female | CheckBox |
Select this checkbox if your current gender designation is Female.
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| Current Mailing Address | ||
| Part 2. Current Information About You. 3. Current Mailing Address. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of your current mailing address. This should be a short identifier, up to 6 characters.
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| Part 2. Current Information About You. 3. Current Mailing Address. Enter City or Town | Text |
Enter the city or town of your current mailing address. This should be the official name of the city or town, up to 20 characters.
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| Part 2. Current Information About You. 3. Current Mailing Address. Select State from List of States | ComboBox |
Select the state of your current mailing address from the provided list of U.S. states and territories.
VT
OH
AK
ID
SD
NV
UT
MI
DC
CT
MA
IL
TX
WI
VI
WY
MO
MS
ME
AE
TN
OR
HI
WA
AR
KY
DE
NC
NE
NH
VA
AL
AS
FL
MD
GA
NY
GU
PR
PW
SC
WV
CA
MT
AZ
AA
NJ
PA
CO
KS
OK
LA
MH
RI
FM
IN
IA
MP
ND
NM
AP
MN
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| Part 2. Current Information About You. 3. Current Mailing Address. Enter Zip Code | Text |
Enter the ZIP code of your current mailing address. This should be a 5-digit code.
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| Part 2. Current Information About You. 3. Current Mailing Address. Enter Province | Text |
Enter the province of your current mailing address, if applicable. This should be the official name of the province, up to 20 characters.
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| Part 2. Current Information About You. 3. Current Mailing Address. Enter Postal Code | Text |
Enter the postal code of your current mailing address, if applicable. This should be a code up to 9 characters.
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| Part 2. Current Information About You. 3. Current Mailing Address. Enter Country | Text |
Enter the country of your current mailing address. This should be the official name of the country.
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| Current Marital Status | ||
| Part 2. Current Information About You. 5. Your Current Marital Status. Select Married | CheckBox |
Check this box if your current marital status is 'Married'.
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| Part 2. Current Information About You. 5. Your Current Marital Status. Select Single | CheckBox |
Check this box if your current marital status is 'Single'.
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| Part 2. Current Information About You. 5. Your Current Marital Status. Select Widowed | CheckBox |
Check this box if your current marital status is 'Widowed'.
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| Date of Birth Change | ||
| Part 6. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth Change. 1. A. Court Order. Date of Court Order (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date of the court order that officially changed your date of birth. Use the format MM/DD/YYYY.
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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 U S C I S error, use Part 4. 1. My date of birth changed through (select all applicable boxes). Select: B. U.S. Government-Issued Document. NOTE: 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) | CheckBox |
Select this checkbox if your date of birth was changed through a U.S. Government-issued document. Attach a copy of the relevant document, such as a birth certificate or certificate of birth abroad.
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| Part 6. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth Change. 1. My date of birth changed through (select all applicable boxes). B. U.S. Government-Issued Document. Date of U.S. Government-Issued Document (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date of the U.S. Government-issued document that officially changed your date of birth. Use the format MM/DD/YYYY.
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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 U S C I S error, use Part 4. 1. My date of birth changed through (select all applicable boxes). Select: A. Court Order. NOTE: If you selected Item A., attach a copy of either the original or certified court document | CheckBox |
Select this checkbox if your date of birth was changed through a court order. Attach a copy of the original or certified court document.
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| Part 6. Complete If Applying for a New Certificate of Citizenship Because of an Official Date of Birth Change. 2. My new date of birth is (as shown in the court order or U.S. Government-issued document). New Date of Birth. Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter your new date of birth as shown in the court order or U.S. Government-issued document. Use the format MM/DD/YYYY.
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| Document Correction | ||
| Part 4. Complete If Applying to Correct Your Document Due to a U S C I S Typographical or Clerical Error. 2. Enter an explanation of what is incorrect on your current certificate or declaration and attach copies of any documents supporting your request | Text |
Enter an explanation of what is incorrect on your current certificate or declaration due to a USCIS typographical or clerical error, and attach copies of any supporting documents.
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| Part 4. Complete If Applying to Correct Your Document Due to a U S C I S 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). Select this box for: Date of Birth | CheckBox |
Select this checkbox if there is a typographical or clerical error in your document related to your date of birth that needs correction.
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| Part 4. Complete If Applying to Correct Your Document Due to a U S C I S 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). Select this box for: Name | CheckBox |
Select this checkbox if there is a typographical or clerical error in your document related to your name that needs correction.
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| Part 4. Complete If Applying to Correct Your Document Due to a U S C I S 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). Select this box for: Other | CheckBox |
Select this checkbox if there is a typographical or clerical error in your document that needs correction, and it does not fall under the listed categories.
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| Part 4. Complete If Applying to Correct Your Document Due to a U S C I S 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). Select this box for: Gender | CheckBox |
Select this checkbox if you are applying to correct your document due to a typographical or clerical error related to your gender on the original document.
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| Document Information | ||
| Part 1. Information From Current Certificate or Declaration. 4. Enter Certificate or Declaration Number | Text |
Enter the number of your current certificate or declaration. This number is unique to your document.
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| Part 1. Information From Current Certificate or Declaration. 6. Certificate or Declaration Issuance. Provide information about who issued your last certificate or declaration along with the date it was issued. Enter U.S. Citizenship and Immigration Services (U S C I S) Office or Name of Court | Text |
Provide the name of the U.S. Citizenship and Immigration Services (USCIS) office or the name of the court that issued your last certificate or declaration, along with the date it was issued.
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| Foreign Official Address | ||
| 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. 3. Foreign Official's Address. Enter City or Town | Text |
Enter the city or town of the foreign official's address.
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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. 3. Foreign Official's Address. Enter Street Number and Name | Text |
Enter the street number and name of the foreign official's address.
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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. 3. Foreign Official's Address. Select Suite | CheckBox |
Select this checkbox if the foreign official's address includes a suite.
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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. 3. Foreign Official's Address. Select Apartment | CheckBox |
Select this checkbox if the foreign official's address includes an apartment.
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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. 3. Foreign Official's Address. Select Floor | CheckBox |
Select this checkbox if the foreign official's address includes a floor.
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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. 3. Foreign Official's Address. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of the foreign official's address.
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| Foreign Official Information | ||
| 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. 2. Information About Foreign Official. Provide the following information about the official of a foreign country who has requested this certificate (if known). Enter Middle Name | Text |
Enter the middle name of the foreign official who has requested the special certificate of recognition, if known.
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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. 2. Information About Foreign Official. Provide the following information about the official of a foreign country who has requested this certificate (if known). Enter Given Name (First Name) | Text |
Enter the given name (first name) of the foreign official who has requested the special certificate of recognition, if known.
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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. 2. Information About Foreign Official. Provide the following information about the official of a foreign country who has requested this certificate (if known). Enter Family Name (Last Name) | Text |
Enter the family name (last name) of the foreign official who has requested the special certificate of recognition, if known.
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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. 2. Information About Foreign Official. Provide the following information about the official of a foreign country who has requested this certificate (if known). Enter Name of Government Agency | Text |
Enter the name of the government agency of the foreign country whose official has requested the special certificate of recognition.
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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. 2. Information About Foreign Official. Provide the following information about the official of a foreign country who has requested this certificate (if known). Enter Official Title | Text |
Enter the official title of the foreign country official who has requested the special certificate of recognition.
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| Foreign Official's Address | ||
| 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. 3. Foreign Official's Address. Select State from List of States | ComboBox |
Select the state from the list where the foreign official's address is located. This is required if you are applying for a special certificate of recognition as a U.S. citizen to a foreign government.
VT
OH
AK
ID
SD
NV
UT
MI
DC
CT
MA
IL
TX
WI
VI
WY
MO
MS
ME
AE
TN
OR
HI
WA
AR
KY
DE
NC
NE
NH
VA
AL
AS
FL
MD
GA
NY
GU
PR
PW
SC
WV
CA
MT
AZ
AA
NJ
PA
CO
KS
OK
LA
MH
RI
FM
IN
IA
MP
ND
NM
AP
MN
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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. 3. Foreign Official's Address. Enter Zip Code | Text |
Enter the 5-digit zip code for the foreign official's address. This is required if you are applying for a special certificate of recognition as a U.S. citizen to a foreign government.
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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. 3. Foreign Official's Address. Enter Province | Text |
Enter the province for the foreign official's address. This is required if you are applying for a special certificate of recognition as a U.S. citizen to a foreign government.
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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. 3. Foreign Official's Address. Enter Postal Code | Text |
Enter the postal code for the foreign official's address. This is required if you are applying for a special certificate of recognition as a U.S. citizen to a foreign government.
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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. 3. Foreign Official's Address. Enter Country | Text |
Enter the country for the foreign official's address. This is required if you are applying for a special certificate of recognition as a U.S. citizen to a foreign government.
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| Form Metadata | ||
| PDF417BarCode1 | Text |
This field contains a barcode that encodes specific information about the form, including its type and version. It is automatically generated and does not require user input.
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| PDF417BarCode1 | Text |
This field contains a barcode related to the form N-565. It is automatically generated and does not require user input.
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| PDF417BarCode1 | Text |
This field contains a barcode that encodes specific information about the form and its version. No input is required from the user.
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| PDF417BarCode1 | Text |
This is a barcode field related to the form. It contains encoded information about the form type and version.
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| PDF417BarCode1 | Text |
This is a barcode field that contains encoded information about the form. No input is required.
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| Form Processing | ||
| PDF417BarCode1 | Text |
This field contains a PDF417 barcode related to the form N-565. It is used for processing and tracking purposes.
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| Gender Change | ||
| 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 U S C I S error, use Part 4. 1. My gender officially changed through (select all applicable boxes). Select: C. Licensed Health Care Professional's Certification of Gender | CheckBox |
Select this checkbox if your gender was officially changed through a licensed health care professional's certification.
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| Gender Change Documentation | ||
| 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 U S C I S error, use Part 4. 1. My gender officially changed through (select all applicable boxes). Select: B. Government-Issued Document Reflecting the Gender Change | CheckBox |
Select this checkbox if your gender officially changed through a government-issued document reflecting the gender change.
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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 U S C I S error, use Part 4. 1. My gender officially changed through (select all applicable boxes). Select: A. Court Order. NOTE: If you selected Item A., attach a copy of either the original or certified court document | CheckBox |
Select this checkbox if your gender officially changed through a court order. Attach a copy of either the original or certified court document.
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| Interpreter Certification | ||
| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Certification. I certify, under penalty of perjury, that: I am fluent in English and another language, which is the same language provided 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 | Text |
The interpreter must certify, under penalty of perjury, that they are fluent in English and another language, and have accurately translated the application to the applicant.
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| Interpreter Information | ||
| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). Applicant's Statement. 2. 1. Applicant's Statement Regarding the Interpreter. B. Enter Language | Text |
Enter the language in which the interpreter read the application to you, if applicable.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Provide the following information about the interpreter. Interpreter's Full Name. 1. Enter Interpreter's Family Name (Last Name) | Text |
Enter the interpreter's family name (last name).
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Full Name. 1. Enter Interpreter's Given Name (First Name) | Text |
Enter the interpreter's given name (first name).
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| Part 10. Interpreter's Contact Information, Certification, and Signature. 2. Enter Interpreter's Business or Organization Name, if any | Text |
Enter the name of the interpreter's business or organization, if applicable. Maximum length is 30 characters.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Contact Information. 4. Enter Interpreter's Daytime Telephone Number | Text |
Enter the daytime telephone number of the interpreter who is assisting with this application. The number should be 10 digits long.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Contact Information. 5. Enter Interpreter's Mobile Telephone Number, if any | Text |
Enter the mobile telephone number of the interpreter, if available. The number should be 10 digits long.
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| Interpreter Mailing Address | ||
| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter Street Number and Name | Text |
Enter the street number and name for the interpreter's mailing address. Maximum length is 25 characters.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Select Suite | CheckBox |
Check this box if the interpreter's mailing address includes a suite number.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Select Apartment | CheckBox |
Check this box if the interpreter's mailing address includes an apartment number.
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| Interpreter Signature | ||
| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Signature. 7. Date of Signature (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date the interpreter signed the form. Use the format MM/DD/YYYY.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Signature. 7. Interpreter's Signature. This form can not be signed electronically. The name of the interpreter can not be typewritten into this space. Print and sign | Text |
The interpreter must print and sign their name in this space. Electronic signatures are not accepted.
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| Interpreter's Contact Information | ||
| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Contact Information. 6. Enter Interpreter's Email Address, if any | Text |
Enter the interpreter's email address, if available.
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| Interpreter's Mailing Address | ||
| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Select Floor | CheckBox |
Select the floor number of the interpreter's mailing address, if applicable.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of the interpreter's mailing address. Maximum length is 6 characters.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter City or Town | Text |
Enter the city or town of the interpreter's mailing address. Maximum length is 20 characters.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Select State from List of States | ComboBox |
Select the state from the list of states for the interpreter's mailing address.
VT
OH
AK
ID
SD
NV
UT
MI
DC
CT
MA
IL
TX
WI
VI
WY
MO
MS
ME
AE
TN
OR
HI
WA
AR
KY
DE
NC
NE
NH
VA
AL
AS
FL
MD
GA
NY
GU
PR
PW
SC
WV
CA
MT
AZ
AA
NJ
PA
CO
KS
OK
LA
MH
RI
FM
IN
IA
MP
ND
NM
AP
MN
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter Zip Code | Text |
Enter the 5-digit zip code of the interpreter's mailing address.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter Province | Text |
Enter the province of the interpreter's mailing address, if applicable. Maximum length is 20 characters.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter Postal Code | Text |
Enter the postal code of the interpreter's mailing address. Maximum length is 9 characters.
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| Part 10. Interpreter's Contact Information, Certification, and Signature. Interpreter's Mailing Address. 3. Enter Country | Text |
Enter the country of the interpreter's mailing address.
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| Mailing Address | ||
| Part 2. Current Information About You. 3. Current Mailing Address. Enter In Care Of Name | Text |
Enter the name of the person in care of whom the mail should be sent, if applicable. Maximum length is 34 characters.
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| Part 2. Current Information About You. 3. Current Mailing Address. Enter Street Number and Name | Text |
Enter the street number and name of your current mailing address. Maximum length is 34 characters.
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| Part 2. Current Information About You. 3. Current Mailing Address. Select Suite | CheckBox |
Check this box if your mailing address includes a suite number.
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| Part 2. Current Information About You. 3. Current Mailing Address. Select Apartment | CheckBox |
Check this box if your mailing address includes an apartment number.
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| Part 2. Current Information About You. 3. Current Mailing Address. Select Floor | CheckBox |
Check this box if your mailing address includes a floor number.
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| Marital Status | ||
| Part 2. Current Information About You. 5. Your Current Marital Status. Select Divorced | CheckBox |
Select this checkbox if your current marital status is 'Divorced'.
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| Part 2. Current Information About You. 4. Has your marital status changed since your last document was issued? Select No | CheckBox |
Select 'No' if your marital status has not changed since your last citizenship or naturalization document was issued.
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| Part 2. Current Information About You. 4. Has your marital status changed since your last document was issued? Select Yes | CheckBox |
Select 'Yes' if your marital status has changed since your last citizenship or naturalization document was issued.
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| Part 2. Current Information About You. 5. Your Current Marital Status. Select Marriage Annulled | CheckBox |
Select this checkbox if your current marital status is 'Marriage Annulled'.
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| Name Change Details | ||
| Part 5. Complete If Applying for a New Document Because of a Name Change. 2. My new legal name is. Enter Middle Name | Text |
Enter your new legal middle name as it should appear on the document.
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| Part 5. Complete If Applying for a New Document Because of a Name Change. 2. My new legal name is. Enter Given Name (First Name) | Text |
Enter your new legal given name (first name) as it should appear on the document.
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| Part 5. Complete If Applying for a New Document Because of a Name Change. 2. My new legal name is. Enter Family Name (Last Name) | Text |
Enter your new legal family name (last name) as it should appear on the document.
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| Name Change Documentation | ||
| Part 5. Complete If Applying for a New Document Because of a Name Change. 1. My name changed through (select only one box). B. Court Order. Enter Date of Court Order (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date of the court order that legally changed your name. Use the format MM/DD/YYYY.
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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 U S C I S error, use Part 4. 1. My name changed through (select only one box). Select: B. Court Order. NOTE: If you selected Item B., attach a copy of either the original or certified court document | CheckBox |
Select this checkbox if your name changed through a court order. Ensure to attach a copy of the original or certified court document.
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| Part 5. Complete If Applying for a New Document Because of a Name Change | CheckBox |
Select this checkbox if you are applying for a new document due to a name change.
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| Part 5. Complete If Applying for a New Document Because of a Name Change. 1. A. Marriage, Divorce or Annulment. Enter Date of Event (m m / d d / y y y y). Enter dates as 2-digit Month, 2-digit Day, and 4-digit Year. NOTE: If you selected Item A., attach a copy of your marriage certificate, annulment decree, or divorce decree | Date |
Enter the date of your marriage, divorce, or annulment that resulted in a name change. Use the format MM/DD/YYYY. Attach the relevant certificate or decree.
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| Other Names Used | ||
| Part 2. Current Information About You. 2. Other Names Used. Line One. Enter Middle Name | Text |
Enter any middle name you have used other than your current legal name.
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| Part 2. Current Information About You. 2. Other Names Used. Line Two. Enter Family Name (Last Name) | Text |
Enter any family name (last name) you have used other than your current legal name.
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| Part 2. Current Information About You. 2. Other Names Used. Line Two. Enter Given Name (First Name) | Text |
Enter any given name (first name) you have used other than your current legal name.
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| Part 2. Current Information About You. 2. Other Names You Have Used. Line Two. Enter Middle Name | Text |
Enter any middle name you have used other than your current legal name.
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| Part 2. Current Information About You. 2. Other Names Used. Line One. Enter Given Name (First Name) | Text |
Enter any given name (first name) you have used other than your current legal name.
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| Part 2. Current Information About You. 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. Line One. Enter Family Name (Last Name) | Text |
Provide all other family names (last names) you have ever used, including aliases, maiden name, and nicknames. Use Part 12 for additional space if needed.
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| Personal Information | ||
| 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. Enter Middle Name | Text |
Enter your middle name exactly as it appears on your current citizenship or naturalization certificate or declaration.
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| 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. Enter Given Name (first name) | Text |
Enter your given name (first name) exactly as it appears on your current citizenship or naturalization certificate or declaration.
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| 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. Enter Family Name (last name) | Text |
Enter your family name (last name) exactly as it appears on your current citizenship or naturalization certificate or declaration.
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| Part 1. Information From Current Certificate or Declaration. 3. Enter Country of Former Citizenship or Nationality | Text |
Enter the country of your former citizenship or nationality as it appears on your current certificate or declaration.
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| Part 1. Information From Current Certificate or Declaration. 5. Enter Alien Registration Number (A Number) | Number |
Enter your Alien Registration Number (A-Number), which is a unique 9-digit number assigned to you by USCIS.
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| Part 2. Current Information About You. 1. Your Full Legal Name (Do not provide a nickname). Enter Middle Name | Text |
Enter your middle name as it appears on your legal documents. Do not use a nickname.
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| Part 2. Current Information About You. 1. Your Full Legal Name (Do not provide a nickname). Enter Given Name (First Name) | Text |
Enter your given name (first name) as it appears on your legal documents. Do not use a nickname.
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| Part 2. Current Information About You. 1. Your Full Legal Name (Do not provide a nickname). Enter Family Name (Last Name) | Text |
Enter your family name (last name) as it appears on your legal documents. Do not use a nickname.
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| Part 12. Additional Information. 1. Middle Name. This is a read only field. This field is pre-populated from Page 1 | Text |
This field displays the middle name of the applicant. It is pre-populated from the information provided on Page 1 and cannot be edited.
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| Part 12. Additional Information. 1. Given Name (First Name). This is a read only field. This field is pre-populated from Page 1 | Text |
This field displays the given name (first name) of the applicant. It is pre-populated from the information provided on Page 1 and cannot be edited.
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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. 1. Family Name (Last Name). This is a read only field. This field is pre-populated from Page 1 | Text |
This field displays the family name (last name) of the applicant. It is pre-populated from the information provided on Page 1 and cannot be edited.
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| Part 12. Additional Information. 2. Alien Registration Number (A. Number), if any. This is a read only field. This field is pre-populated from Page 1 | Text |
This field displays your Alien Registration Number (A-Number) if applicable. It is pre-populated from Page 1 and cannot be edited.
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| Preparer Information | ||
| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). 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. 2. Applicant's Statement Regarding the Preparer. Select this box for: At my request, the preparer named in Part 11., prepared this application for me based only upon information I provided or authorized | CheckBox |
Select this checkbox if the preparer named in Part 11 prepared this application for you based on information you provided or authorized.
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| Part 9. Applicant's Statement, Contact Information, Certification, and Signature (continued). 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. 2. Applicant's Statement Regarding the Preparer. Enter Name of Preparer | Text |
Enter the name of the preparer who assisted you with this application, if applicable.
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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. 1. Enter Preparer's Family Name (Last Name) | Text |
Enter the last name (family name) of the person preparing this application, if it is someone other than the applicant.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Full Name. 1. Enter Preparer's Given Name (First Name) | Text |
Enter the first name (given name) of the person preparing this application, if it is someone other than the applicant.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. 2. Enter Preparer's Business or Organization Name, if any | Text |
Enter the business or organization name of the preparer, if applicable.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Statement. 7. B. Select I am an attorney or accredited representative and my representation of the applicant in this case extends beyond the preparation of this application | CheckBox |
Select this checkbox if you are an attorney or accredited representative and your representation of the applicant extends beyond the preparation of this application.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Statement. 7. B. Select I am an attorney or accredited representative and my representation of the applicant in this case does not extend beyond the preparation of this application | CheckBox |
Select this checkbox if you are an attorney or accredited representative and your representation of the applicant does not extend beyond the preparation of this application.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. 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. This form can not be signed electronically. The name of the preparer can not be typewritten into this space. Print and sign | Text |
Provide your handwritten signature as the preparer of this application. Note that electronic signatures are not accepted, and the name cannot be typewritten.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Signature. 8. Date of Signature (m m / d d / y y y y). Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date you signed this application as the preparer, using the format MM/DD/YYYY.
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| Preparer's Contact Information | ||
| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Contact Information. 6. Enter Preparer's Email Address, if any | Text |
Enter the email address of the person who prepared this application, if it is someone other than the applicant. This field is optional.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Contact Information. 5. Enter Preparer's Mobile Telephone Number, if any | Text |
Enter the mobile telephone number of the person who prepared this application, if it is someone other than the applicant. This field is optional and should be a 10-digit number.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Contact Information. 4. Enter Preparer's Daytime Telephone Number | Text |
Enter the daytime telephone number of the person who prepared this application, if it is someone other than the applicant. This should be a 10-digit number.
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| Preparer's Mailing Address | ||
| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter Street Number and Name | Text |
Enter the street number and name of the mailing address for the person who prepared this application, if it is someone other than the applicant. The maximum length is 34 characters.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Select Suite | CheckBox |
Select this checkbox if the mailing address of the person who prepared this application includes a suite number.
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| Part 11. Contact Information, Decla1ation, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Select Apartment | CheckBox |
Select this checkbox if the mailing address of the person who prepared this application includes an apartment number.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Select Floor | CheckBox |
Select this checkbox if the mailing address of the person who prepared this application includes a floor number.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter Apartment, Suite or Floor Number | Text |
Enter the apartment, suite, or floor number of the mailing address for the person who prepared this application, if it is someone other than the applicant. The maximum length is 6 characters.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter City or Town | Text |
Enter the city or town of the mailing address for the person who prepared this application, if it is someone other than the applicant. The maximum length is 20 characters.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Select State from List of States | ComboBox |
Select the state from the list where the preparer of this application resides.
VT
OH
AK
ID
SD
NV
UT
MI
DC
CT
MA
IL
TX
WI
VI
WY
MO
MS
ME
AE
TN
OR
HI
WA
AR
KY
DE
NC
NE
NH
VA
AL
AS
FL
MD
GA
NY
GU
PR
PW
SC
WV
CA
MT
AZ
AA
NJ
PA
CO
KS
OK
LA
MH
RI
FM
IN
IA
MP
ND
NM
AP
MN
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter Zip Code | Text |
Enter the 5-digit ZIP code for the mailing address of the person preparing this application.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter Province | Text |
Enter the province for the mailing address of the person preparing this application, if applicable.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter Postal Code | Text |
Enter the postal code for the mailing address of the person preparing this application. This can be up to 9 characters long.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Mailing Address. 3. Enter Country | Text |
Enter the country for the mailing address of the person preparing this application.
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| Preparer's Statement | ||
| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Statement. 7. A. Select I am not an attorney or accredited representative but have prepared this application on behalf of the applicant and with the applicant's consent | CheckBox |
Check this box if you are not an attorney or accredited representative but have prepared this application on behalf of the applicant with their consent.
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| Part 11. Contact Information, Declaration, and Signature of the Person Preparing this Application, if Other Than the Applicant. Preparer's Statement. 7. B. Select I am an attorney or accredited representative. NOTE: If you are an attorney or accredited representative, you may need to submit a completed Form G-28, Notice of Entry of Appearance as Attorney or Accredited Representative with this application | CheckBox |
Check this box if you are an attorney or accredited representative. Note that you may need to submit a completed Form G-28 with this application.
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| Reference Information | ||
| Part 12. Additional Information. 4. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced. This helps in organizing and cross-referencing your additional details.
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| Part 12. Additional Information. 4. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced. This helps in organizing and cross-referencing your additional details.
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| Part 12. Additional Information. 4. C. Enter Item Number | Text |
Enter the item number of the form where the additional information is referenced. This helps in organizing and cross-referencing your additional details.
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| Part 12. Additional Information. 5. A. Enter Page Number | Text |
Enter the page number of the form where the additional information is referenced. This helps in organizing and cross-referencing your additional details.
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| Part 12. Additional Information. 5. B. Enter Part Number | Text |
Enter the part number of the form where the additional information is referenced. This helps in organizing and cross-referencing your additional details.
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| Special Certificate Application | ||
| 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. Enter Name of Foreign Country | Text |
Enter the name of the foreign country for which you are applying for a special certificate of recognition as a U.S. citizen.
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| USCIS or Consular Official's Certification | ||
| 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. 4. U S C I S or Consular Official's Certification. Date of Signature. Enter date as 2-digit Month, 2-digit Day, and 4-digit Year | Date |
Enter the date of signature by the USCIS or consular official in the format MM/DD/YYYY. This is part of the certification process for a special certificate of recognition.
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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. U S C I S or Consular Official's Certification. NOTE: The U S C I S or consular official's certification will be completed after U S C I S adjudicates your Form N-5 65, if it is approved. You do not need to obtain this signature before filing this application. 4. U S C I S or Consular Official's Certification. U S C I S or Consular Official's Signature. This form can not be signed electronically. The name of the official can not be typewritten into this space. Print and sign | Text |
This field is for the signature of the USCIS or consular official. Note that this signature will be completed after USCIS adjudicates your Form N-565, if approved. You do not need to obtain this signature before filing the application.
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