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in the year
Declaration for Renewal. [Naval Case.) TO TE COMMISSIONER OF PENSIONS :
The memorial of the undersigneci, the widow of the late .. who was a in the navy of the United States, respectfully shows:
That her husband, the aforesaid entered the service of the United States in the year —; that while in the said service and holding the rank above mentioned, he departed this life at day of
-; that the undersigned was married to the said on the day of - in the vear
and in proof thereof, she refers to papers on file in the Pension Office, upon which she obtained a pension for five years. She therefore claims the benefits of the act of Congress of the granting pensions to the widows of officers, seamen and marines, who have died in the service aforesaid ; and she requests that her name may be inscribed on the roll of pensiong under that law, who are paid at in the State of
[Claimant's Signature.] Here must follow a certificate of the judge or clerk, as in the case of a widow whose husband was in the military service.
The same proof as in the last-mentioned case must accompany the declaration, and a power of attorney must also be executed in such cases.
INCREASE OF PENSIONS.
Regulations. No application for an increase of an invalid pension wil be examined, unless the proof be first presented to the Pension Agent, where the payment is made. He will forward the “Surgeon's Affidavit,” the “Pension Certificate," etc., to the Department of the Interior,
If the applicant was pensioned on account of a wound roeived previous to the war of 1812, he should be examined by two surgeons, under a commission issued hy a judge of one of the United States courts, in order to cbtand an increase of his pension.
The magistrate who may administer the oath to the surgeous mnst certify that they are respectable in their professions, or le lieves, on the information of others, that they are so. And the official character of the magistrate must be certified vy a proper officer under his seal of office.
If the claimant be within thirty miles of an army surgeon, le nuss obtain his testimony.
Application for Increase. (Army Case.]
On this day of _, A. D. 18, before me, a within and for said county, personally appeared dent of said county, aged years, who, being by me first duly sworn, declares that he is the same person in whose favor a certificate of pension was issued on the 184, by the Secretary of the Interior, at the rate of per month, from the day of 18%; and which pension has been paid to him to the
18—; at the agency of -, in the State of
That the disability for which the said pension was allowed was caused by in the line of his duty as a in company
in the regiment of in the war with and was graduated for [state the degree of disability for which the said pension was allowed, as: one-fourth, one-half, or otherwise) disability from manual labor. That said disability has since increased (here give the nature and effect of the increase] and renders him less able than formerly to perform manual labor, as will appear by the surgeon's affidavit herewith filed.
He makes this declaration for the purpose of obtaining an increase of his pension, corresponding with the increase of his disability as aforesaid.
Claimant's Signature.] Sworn to and subscribed before me, the day and year afore baid; and I certify that I have no interest whatever in the foregoing claim.
Surgeon's Affidavit. It is hereby certified that
formerly of Captain -_'s company, in the regiment of — who, it
appears by the accompanying pension certificate, was placed on the penbion roll at the rate of dollars per month, on account, as he states, of having received a [here give a particular description of the sound, injury, or disease, and specify in what manner it hizo
in the year
affected the applicant 80 as to produce disability in the legree ste ted; and show its origin and progress], while in the line of duty, anc in the said service, on or about the at a place called in the State of
is not only still disabled in consequence of the said injury, but in the opinion of the undersigned, is entitled to (one-fourth, one-half, or, ns the case may be), more than he already receives as a penGioner, being disabled to a degree amounting to this must be fillea up with the degree of disability, as one-fourth, one-third, one-half, three-fourths) a total disability.
[Signatures of two Surgeons.) Sworn to and subscribed before me, the day and year afore. said; and I certify that I am acquainted with and and know them to be respectable surgeons, in good standing in their profession; and that I have no interest whatever in the above claim.
[Officer's Signature.) To these must be appended the certificate of the clerk of the proper court, under its seal, as to the official character of tho magistrate administering the oaths.
Application for Increase of Navy Invalid Pensions.
per sonally appeared a resident of who being duly sworn, declareth that he is the same person in whose favor a certificate of pension was issued on the under the signature and seal of the Secretary of the Interior, at the rate of dollars cents per month, from the day of
18–, and which pension has been paid him to the
18—, inclusive, at the Navy Pension Agency.
That the disability for which the said pension was allowed was caused by in the line of his duty while attached to the United States (here insert class or name of vessel], and holding the rank of
in the year 18–, and was graduated for (state degree of disability mentioned in certificate) disability from manual labor; but that such disability having increased, the said
-, for the purpose of obtaining a corresponding increaso of his pension, requests that a Board of Survey may be ordered immediately in his case, to be held at the United States Naval Station at
Swomi to and subscribed before me, the day and year afore said; and I certify that I have no interest in the above claim.
[Officer's Signature.) The clerk's certificate and seal must be attached as in other
This declaration must be accompanied by the affidavit of two witnesses, who can svicar to the clainant's identity.
LOSS OF PENSION CERTIFICATES.
Application for Renewal of Lost Certificates.
18—, before the subscriber, a for said county, personally appeared who, on his oath, declares that he is the same person who formerly belonged to the company commanded by Captain in the regiment commanded by Colonel
in the service of the United States; that his name was placed on the pension roll of the State of ; that he received a certificate of that fact under the signature and seal of the Secretary of -; which certificate, on or about the
18–, at or near (here state particulars of loss or destruction of certificate).
[Claimant's Signature.] Sworn to and subscribed before me, the day and year aforesaid; and I certify that I have no interest in the above claim.
[Officer's Signature.] Affidavit of Witness. STATE OF County of On this day of --, 18—, before the subscriber, a
for said county, personally appeared who, on his oath, declares that he well knows
who has executed the foregoing affidavit, to be the identical pensioner named therein. He further says that he has no interest in the above claim.
[Signature of Witness. Bworn to and subscribed before me, the day and year afore paid; and I certify that the said is to me well known to no a person of veracity.
[Officer's Signature.) Append certificate of clerk, under seal, as in other cases.
Form of Application for a Transfer of Pension to another
Pay-Agency STATE OF i'ounty of
} On this
18, before me, the subscriber, a Justice of the Peace for the said county of , personally appeared who, on his oath, declares that he is the same jerson who formerly belonged to the company commanded by Captain – in the regiment commanded by Colonel in the service of the United States; that his name was placed on the pension roll of the State of from whence he has lately removed ; that he now resides in the State of —, where ie intends to remain, and wishes his pension to be there payable in future. The following are his reasons for removing from
Claimant's Signature.] Sworn to and subscribed before ine, the day and year afore said.
A. D. 18—, before me, the subscriber, a in and for said county, duly authorized to adininister oaths, personally came
whom I know to be residents of the county and State aforesaid, and persons whom I know to be respectable and entitled to credit, and who being duly sworn, say that they were present and saw sign and make path to the foregoing affidavit. They further say that they are acquainted with the said
ana know him to be the identical person he represents himself to be, and who inade oath as aforesaid.
[Signature of Witnesses Sworn to and subscribed before me, this A. D. 18—; and I certify that I have no interest in this case, por am I concerned in its prosecution.
[J. P.] The clerk of the proper court must certify, under seal, to the official character of the magistrate.