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Declaration of Intention (I A B do declare on oath)

I, A. B., do declare, on oath, that it is bona fide my intention to become a citizen of the United States, and to renounce forever all allegiance and fidelity to all and any foreign prince, potentate, state, and sovereignty whatever; and particularly to Victoria, Queen of the United Kingdom of Great Britain and Ireland. Sworn in open court, this day of, 18-.

A. B.

I, L. T., clerk of the - court of, do certify that the above is a true copy of the original declaration of intention of A, B. to become a citizen of the United States, remaining of record of my office.

In testimony whereof, I have hereunto subscribed my name and affixed the seal of the said court, the - day of, one thousand eight hundred L. S.] and L. T.