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I. Application of Invalid Pensioner for Payment of Pension.
STATE OF
County of

} Be it known, that before me a Justice of the Peace, in and for the county and State aforesaid, duly authorized by law to administer oaths for general purposes, personally appeared

and made oath, in due form of law, that he is the identical person named in an original certificate in his possession, of which I certify the following is a true copy (here insert a copy of his certificate of pension]: that the said

now resides in and has resided there for the space of years past; and that previous thereto he resided in and that he has not been employed, nor paid in the army, navy, or marine service of the United States from

till

of the truth of which statement I am fully satisfied.

[Signature of Claimant.] [Two Witnesses.)

Sworn to, and subscribed before me, this A. D. 18–

(J. P.] Every two years an examination of the condition of the invalid is required before payment will be made.

day of

II. Power of Attorney.
Know all men by these presents, that I, of

in the State of

do hereby constitute and appoint my true and lawful attorney, for me, and in my name, to receive from the agent of the United States for paying pensions in State of my pension from the

day of 18–, to the day of

18Witness my hand and seal this

day of

18Sealed and delivered in presence of [Two Witnesses.

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III. Acknowledgment. STATE OF County of Be it known, that on this day of 184, before me,

,Justice of the Peace, in and for the county and State afore said, personally appeared above named, and acknow. ledged the foregoing power of attorney to be his act and deed. In testimony whereof, I have hereunto set my hand the day and year last above written.

(J. P.)

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IV. Affidavit of Attorney
STATE OF
County of
Be it known, that on the

day of

18, before mie, a -, duly authorized by law to administer oaths for general purposes, personally appeared —, the attorney named in the foregoing power of attorney, and made oath that he has no interest whatever in the money he is authorized to receive by virtue of the foregoing power of attorney, either by any pledge, mortgage, sale, assignment, or transfer, and that he does not know or believe that the same has been so disposed of to any person whatever.

[Signature of Attorney.] @worn and subscribed, the day and year last above mentioned, before me.

(J. P.] V, Clerk's Certificate, STATE OF County of

I, clerk of the court, within and for said county, dc hereby certify that Esq., before whom the foregoing declaration and power of attorney were made, and who has thereunto subscribed his name, was, at the time of so doing, a Justice of the Peace, in and for the State and county aforesaid, duly commissioned and sworn, and that his signature thereto is genuine.

In testimony whereof, I have hereunto signed my name, (L. B.) and affixed my official seal, this 18

Clerk.

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day of

VI. Widow's Application.

88.

STATE OF
County of 5

Be it known, that lefore me, a Justice of the Peace, in and for the courty aforesaid, duly authorized by law to administer oaths, personally appeared widow of

and made vath in due form of law, that she is the identical person named in an original certificate in her possession, of which (I certify) this is a true copy (here insert a copy of her certificats of pension]: that eke has not intermarried, but continues the widow of the above-mentioned and that she now resides

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in ----, and bas resided there for the space of years past; and that previous thereto she resided in

of the truth of which statement I am fully satisfied.

(Claimant's Signature.] ( Two Witnesses.] Sworn to, and subscribed before me, this

day of A. D. 18

(J. P.] VII. Guardian's Application, STATE OF County of

Be it known, that before me, -, a Justice of the Peace, in and for the county aforesaid, duly authorized by law to administer oaths, personally appeared

guardian of

and made oath in due form of law, that the said is still live ing, and is the identical person named in an orignal certificate in his possession, of which (I certify) the following is a true copy [here insert a copy of the certificate]: that now resides in and has resided there for the space

of

years past; and that previous thereto resided in ; of the truth of which statement I am fully satisfied.

Guardian. [Two Witnesses.]

Sworn to and subscribed before we this A. D. 18–

[J. P.] Here must follow a power of attorney, acknowledgment, affidavit and clerk's certificate, according to the foregoing forms, II., III., IV., V.

“A."
Application of Invalid Naval Pensioner.
STATE OF
County of
Be it known, that before me, a

in and for the county aforesaid, personally appeared an invalid pensioner, and made oath in due form of law, that he is the identical named ån original certificate pension, bearing date at the Department, on the

day of

and signed by St. retary of the -; which certiticate he exhibited to me, and by which it appears that he is entitled ti a pension of - doliars per month.

(Claimants Signature.]

day of

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Sworn to, and subscribed before me, this day of —A. D. 18.

[Officer's Signature.) To this must be added a power of attorney, acknowledgment affidavit, and clerk's certificate, as in army applications.

"B."
Application of Widow Pensioner.
STATE OF
County of

Be it known, that before me, a in and for the county foresaid, personally appeared

widow of

and inade oath in due form of law, that she is the identical named in an original certificate of pension, bearing date at the Department, on the

and signed by the Secretary of the - ; which certificate she exhibited to me, and by which it appears she is entitled to a pension of dollars per month, anu that she has not intermarried, but continues the widow of the said

[Claimant's Signature.) Sworn to, and subscribed before me, this

day of A D. 102.

[Officer's Signature.]

"C."
Application of Guardian of Minor Children.
STATE OF
County of
Be it known, that before me, a

in and for the county aforesaid, personally appeared

guardian of orphan child for children of and made oath in due form of law, that he is the guardian named in the accompanying certificate of guardianship; that his wards are the children of

referred to in an original certificate of pension, bearing date at the

Department, on the day of signed by Secretary of the

; by which it appears that they are entitled to a pension of dollars per month; and that said children are still living, and not over sixteen years of age.

[Claimant's Signature.] Sworn to, and subscribed before me, this day of A D. 18.

(Officer's Signature.)

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83.

Surgeon's Affidavit. We, the subscribers, practicing physicians jor surgeons) in the town of county of and State of

do hereby certify that we have carefully examined

who is now on the invalid pension roll of the agency of in the State of

-, and find that [here describe his present physical condition and disability). And further, that his present disability for obtaining subsistence by manual labor amounts to [one-fourth, onethird, one-half, two-thirds, three-fourths, or total, as the case may be.]

Physicians (or Surgeons.] Sworn to and subscribed before me this

A. I). 18—; and I certify that I am acquainted with the said and

and know them to be physicians (or surgeons) in good standing in said town of as to skill and integrity.

[Officer's Signature.] Oath of Allegiance. STATE OF County of

I, a pensioner of the United States, do solemnly that I will support, protect and defend the Constitution and Government of the United States, against all enemies, whether domestic or foreign, and I will bear true faith, allegiance and loyalty to the same, any ordinance, resolution or law of any State Convention or Legislature to the contrary notwithstanding; and further, that I do this with a full determination, pledge and purpose, without any mental reservation or evasion what soever; and further, that I will well and faithfully perform all the duties which may be required of me by law. So help me God.

[Pensioner's Signature.] Subscribed and sworn to before me this

day of 18

[Officer's Signature.) STATE OF County of

I, clerk of the -court, within and for said county, do hereby certify that Esq., before whom the foregoing declaration and power of attorney were made, and who has thereunto subscribed his name, was at the time of his so doing a Justice of the Peace, in and for the said State and county, dilly commissioned and sworn, and that his siguature thereto is genuine

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