North Carolina State Board of CPA Examiners
PO Box 12827
Raleigh, NC 27605-2827
DECLARATION OF INTENTION TO BECOME A US CITIZEN
I, , intend to become a citizen of the
United States of America. I affirm that the facts presented in the foregoing statement are true to the
best of my knowledge and belief.
Signature: Date:
State
County
Signed and sworn to (or affirmed) before me this day by
(Name of Person Signing Form)
Witness my hand and official seal, this the _____ day of , 20 .
Official Signature of Notary
, Notary Public
Notary’s printed or typed name
My commission expires:
04/2015