OMB No. 1615-0091; Expires 04/30/2010
START HERE - Please type or print in black ink.
Information about you.
Address - In care of:
Street Number and Name
State or Province
City or town
Zip or Postal Code
Date of Birth (mm/dd/yyyy)
Country of Birth
Part 2. Type of application.
1. I hereby apply for: (check one)
New Certificate of Citizenship.
New Certificate of Naturalization.
New Certificate of Repatriation.
New Declaration of Intention.
Special Certificate of Naturalization to obtain recognition of my U.S. citizenship by a
2. Basis for application: (If you checked other than "e" in Part 1, check one)
My certificate is/was lost, stolen or destroyed (attach a copy of the certificate if you
have one). Explain when, where and how.
My certificate is mutilated (attach the certificate).
My name has been changed (attach the certificate).
My certificate or declaration is incorrect (attach the documents).
Part 3. Processing information.
My last certificate or Declaration of Intention was issued to me by:
USCIS Office or Name of Court
Name in which the document was issued:
Other names I have used (if none, so indicate):
Since becoming a citizen, have you lost your citizenship in any manner?
Yes (attach an explanation)
Part 4. Complete if applying for a new document
because of a name change.
Name changed to present name by: (check one)
Marriage or divorce on (month/day/year)
(Attach a copy of marriage or divorce certificate)
Court Decree (month/day/year)
(Attach a copy of the court decree)
Department of Homeland Security
U.S. Citizenship and Immigration Services
N-565, Application for Replacement
For USCIS Use Only
Fill in box if G-28 is attached to
represent the applicant.
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