PETITION FOR DECLARATORY RULING

On Rule No._____________________________

1. 1. Petitioner

   Name:____________________________________________________________
   Address:_________________________________________________________
   Telephone:_______________________________________________________

2. 2. All rules or statutes that may be involved in the petition, if known: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
3. 3. Clear and concise statement of the precise factual situation involved: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
4. 4. The exact question to which an answer is desired: ______________________________________________________________________
5. 5. The reason for submitting the petition: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
6. 6. Full disclosure of the petitioner's interest: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
7. 7. Statement as to whether the petitioner's case is presently under consideration by the Board of Public Accountancy or in any pending proceeding: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

8. 8. Affidavit Certification:
   Signature of Petitioner
   ______________________________________________________________________

   Sworn to and subscribed before me this the____________________day of ______________________, 19_____.

   ________________________________________
   Notary Public