I, Jan Norin, do hereby, upon oath, declare that I first arrived in the United States on or about the ??^th day of ??, in the year A.D. 1870, and that I have, ever since that time, continued to reside in the United States, and that it is bona fide my intention to become a CITIZEN OF THE UNITED STATES, and to renounce forever all allegiance and fidelity which I in anywise owe to any foreign Prince, Potentate, State or Sovereignty, and particularly all allegiance which I owe to the King of Sweden and Norway of whom I have heretofore been a subject.

Subscribed and sworn to before me, this ??^th day of ?? A.D. 1870.