Sworn 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

cases.

This declaration must be accompanied by the affidavit of two witnesses, who can swear to the claimant's identity.

LOSS OF PENSION CERTIFICATES.
Application for Renewal of Lost Certificates.

STATE OF
County of
On this

89.

}

day of

18-, before the subscriber, a

for said county, personally appeared

་

who, on his

in the regiment

oath, declares that he is the same person who formerly belonged to the company commanded by Captain 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 day of, 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.]

who, on his

for said county, personally appeared 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.]

Sworn to and subscribed before me, the day and year aforesaid; and I certify that the said is to me well known to

be a person of veracity.

[Officer's Signature.]

Append certificate of clerk, under seal, as in other cases.

TRANSFER OF PAY AGENCY.

Form of Application for a Transfer of Pension to another Pay-Agency.

On this

day of

18-, before me, the subscriber, a -, 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

Justice of the Peace for the said county of

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

he intends to remain, and wishes his pension to be there payable in future. The following are his reasons for removing from

10

Claimant's Signature.]

Sworn to and subscribed before me, the day and

said.

year afore

Affidavit of Witness.

STATE OF
County of
On this

88.

day of

scriber, a

[J. P.]

A. D. 18-, before me, the sub

and

in and for said county, duly authorized to adninister 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 oath to the foregoing affidavit. They further say that they are acquainted with the said and know him to be the identical person he represents himself to be, and who made oath as aforesaid.

[Signature of Witnesses.] day of

Sworn to and subscribed before me, this

A. D. 18-; and I certify that I have no interest in this case, nor 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.

I. Application of Invalid Pensioner for Payment of Pension.

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

and has resided there for the space of

now resides in years past; and that he has

and that previous thereto he resided in not been employed, nor paid in the army, navy, or marine service of the United States from which statement I am fully satisfied.

till

of the truth of

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

II. Power of Attorney.

Know all men by these presents, that I, —

the State of

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 my pension from the

State of

18-, to the day of

Witness my hand and seal this

Sealed and delivered in presence of [Two Witnesses.]

day of

18-
day of

18-, 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.J

STATE OF
County of

IV. Affidavit of Attorney

83.

Be it known, that on the day of-- 18-, before me. 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.]

Sworn and subscribed, the day and year last above mentioned, before me.

[J. P.]

V. Clerk's Certificate.

STATE OF

County of

}

88.

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 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.

[L. 8.]

In testimony whereof, I have hereunto signed my name,
and affixed my official seal, this
18-.

VI. Widow's Application.

day of

Clerk.

Be it know, that before 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 oath 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 certificate of pension]: that she has not intermarried, but continues the widow of the above-mentioned and that she now resides

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

STATE OF

County of

VII. Guardian's Application.

88.

Be it known, that before me,

day of

[J. P.]

a Justice of the Peace, in

guardian of

and for the county aforesaid, duly authorized by law to administer oaths, personally appeared

and made oath in due form of law, that the said is still living, 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

and has resided there for the space of

;

now resides in

years past; of the truth of

and that previous thereto - resided in which statement I am fully satisfied.

Guardian.

[Two Witnesses.]

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

day of

[J. P.]

Here must follow a power of attorney, acknowledgment, affidavit, and clerk's certificate, according to the foregoing forms, II., III., i√., V.

STATE OF
County of

"A."

Application of Invalid Naval Pensioner.

}

88.

Be it known, that before me, a aforesaid, personally appeared

in and for the county an invalid pensioner, and

made oath in due form of law, that he is the identical

named in an original certificate of pension, bearing date at the

Department, on the

St. retary of the

dollars per month.

day of

and signed by ; which certificate he exhibited

to me, and by which it appears that he is entitled to a pension

of

[Claimant's Signature.]