State of New York
In the Court of Common Pleas for the City and County of New York.
I, Helen P Blovatsky 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 any foreign Prince, Potentate, State or Sovereignty whatever, and particularly to the Emperor of Russia, of whom I am a subject.
|Sworn, this 22 day }
of Sept 1874 }
Nathaniel Jarvis, Jr.
|Clerk's Office, Court of Common Pleas }
for the City and County of New York. }
|I certify, that the foregoing is a true copy of an original Declaration of Intention remaining of record in my office.|
In ATTESTATION WHEREOF, I have hereunto subscribed my name, and affixed the Seal of said Court, this 22 day of Sept 1874.
N. Jarvis Jr. Clerk.
[Editor's Note: This is a printed form with the blanks filled in. H.P.B.'s name is written "Blovatsky" both times it occurs.]