North Carolina State Board of Certified Public Accountant Examiners
1101 Oberlin Road Suite 104 • PO Box 12827 • Raleigh NC 27605
Phone 919-733-1423 • Fax 919-733-4209 • Web nccpaboard.gov
AFFIDAVIT OF LOST OR DESTROYED CPA FIRM REGISTRATION CERTIFICATE
I, , acknowledge that the firm registration certificate
(your name)
for , a North Carolina
(CPA firm name)
CPA firm for the year , was either lost or destroyed on .
(year) (month/day/year)
I
have made a diligent search for the registration certificate granted to the above-named CPA firm and have
been unable to locate the registration certificate. I affirm that should this certificate be located, I will
immediately return it to the Board's office at 1101 Oberlin Road, Suite 104, Raleigh, NC 27605. I understand
that it is a violation of North Carolina General Statutes to refer to the firm as a CPA firm unless the firm is
properly registered with the North Carolina State Board of CPA Examiners.
Date: Signature:
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:
REVISED 04/14/2015
