I, ________, do solemnly declare on oath to ________, clerk of the district court of the county of ________, and state of ________, that it is bona fide my intention to become a citizen of the United States, and to renounce forever all allegiance and fidelity to any foreign prince, potentate, state or sovereignty whatever, and particularly to the sovereign of ________, whereof I was heretofore a citizen or subject.
(Signed.)
Subscribed and sworn to before me this _____ day of _______, A.D. 18__.
Clerk of said Court.
State of _______,}
County of ______}ss
I hereby certify that the foregoing is a true copy of the original declaration of _______, this day filed in my office.
In testimony whereof, I have hereunto subscribed my name and affixed the seal of the district court aforesaid, at _______, this ____ day of _______, A.D. 18__.
Clerk.
(Second Paper.)
State of _______,}
County of ______}ss