File No. STATE OF NORTH CAROLINA R Film No. County In The General Court Of Justice Superior Court Division Before The Clerk In The Matter Of The Restoration Of Citizenship Of: Name And Address CERTIFICATE OF RESTORATION Social Security No. Race OF CITIZENSHIP Drivers License No. & State Sex Date Of Birth G.S. 13-2 The person named above is a resident of the county named above and was convicted of a crime against the United States or another state whereby citizenship rights were forfeited. Pursuant to Section 13-2(b) of the North Carolina General Statutes, that person has presented to the undersigned a paper writing from the agency of the United States or of the state which had jurisdiction over the person named above, stating that on the date shown below, the person named above was: 1. unconditionally discharged by that agency. 2. pardoned by the President of the United States or the Governor of the state in which the person named above was convicted, and that his/her pardon was: a. unconditional. b. conditional and the person named above has satisfied the conditions of the pardon. By virtue of Section 13-1 of the North Carolina General Statutes, the citizenship rights of the person named above have automatically been restored. Date Of Discharge Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court Assistant CSC Clerk Of Superior Court CERTIFICATION I certify that this is a true and complete copy of the original on file in this office. Signature Date Deputy CSC NOTE TO CLERK OF SUPERIOR COURT: Place the original of this certificate in your registration file and give a certified copy to the named person. The fee for recording a document applies. G.S. 7A-308(a)(11). NOTE TO PETITIONER: You are eligible to vote now that your citizenship rights have been restored. To vote, you must register with your local Board of Elections. AOC-CR-919M, Rev. 12/07 © 2007 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkflow.com