Sworn to, and subscribed before me, this A. D. 18-. day of [Officer's Signature.] To this must be added a power of attorney, acknowledgment affidavit, and clerk's certificate, as in army applications. nade 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 day of 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, and that she has not intermarried, but continues the widow of the said [Claimant's Signature.] day of [Officer's Signature.] Sworn to, and subscribed before me, this A D. 18. "C." STATE OF County of Application of Guardian of Minor Children. } 88. Be it known, that before me, a aforesaid, personally appeared orphan child [or children] of day of. 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 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. Sworn to, and subscribed before me, this A. D. 18 and [Claimant's Signature.] day of [Officer's Signature.] Surgeon's Affidavit. County of and State of We, the subscribers, practicing physicians or surgeons] in the town of by certify that we have carefully examined the invalid pension roll of the agency of do herewho is now on 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.] day of A. D. and Sworn to and subscribed before me this 18-; and I certify that I am acquainted with the said and know them to be physicians [or surgeons] in good standing in said town of, as to skill and integrity. STATE OF [Officer's Signature.] 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. 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, duly commissioned and sworn, and that his signature thereto is genuine, [1.. 8.] In testimory whereof I have hereunto signed my name and affixed my offical seal, this 18-. day of Clerk. I. Form of Declaration to be made by a Person who has never before had a Land Warrant nor made a Declaration therefor. STATE OF On this and 88. day of, A. D. one thousand eight hundred personally appeared before me, a Justice of the Peace [or other officer authorized to administer oaths for general purposes], within and for the county and State aforesaid, —, agedyears, a resident of. in the State of who, being duly sworn according to law, declares that he is the identical who was a --- in the company commanded by Captain —, in regiment, commanded by, in the war with Great Britain, declared by the United States, on the 18th day of June, 1812 for other war embraced in said act, describing what war]; that he enlisted [or volunteered or was drafted], at on or about the day of, A. D. for the term of the and continued in actual service in said war for the term of fourteen days, and was honorably discharged at day of —, A. D. on the He makes this declaration for the purpose of obtaining the bounty land to which he may be entitled under the act approved March 3, 1855. He also declares that he has not received a warrant for bounty land under this or any other act of Congress, nor made any other application therefor. We, - and residents of [Claimant's Signature.] in the State of —, upon our oaths declare that the foregoing declaration was signed and acknowledged by -, in our presence, and that we believe, from the appearance and statements of the applicant, that he is the identical person he represents himself to be. [Signatures of Witnesses.] The foregoing declaration and affidavit were sworn to and subscribed before me, on the day and year above written; and I certify that I know the affiants to be credible persons, that the claimant is the person he represents himself to be, and that I. have no interest in kis claim. [J. P.] II. Form of a Declaration to be made where the Party has had a Warrant and desires another. STATE OF day of aged who was - in the A. D. one thousand eight hundred and personally appeared before me a Justice of the Peace [or other officer authorized to administer oaths for general purposes), within and for the county aforesaid, years, a resident of, in the State of, who, being by me duly sworn according to law, declares that he is the identical a in the company commanded by Captain regiment of in the war with Great Britain, declared by the United States on the 18th day of June, 1812 [or other war as the case may be], for the term of - and continued in actual service in said war for fourteen days; that he has heretofore made application for bounty land, under the "act of September 28, 1850" [or other act, as the case may be], and received a land warrant, No. for acres, which he commanded by has since legally disposed of, and cannot now return. He makes this declaration for the purpose of obtaining the additional bounty land to which he may be entitled under the "act approved the 3d day of March, 1855." He also declares that he has never applied for nor received under this act nor any other act of Congress, any bounty land warrant, except the one above mentioned. [Signature of the Claimant.] We, -and-, residents of, in the State of upon our oaths declare that the foregoing declaration was signed and acknowledged by · - in our presence, and that we believe, from the appearance and statements of the applicant, that he is the identical person he represents himself to be. [Signatures of Witnesses.] The foregoing declaration and affidavit were sworn to and subscribed before me on the day and year above mentioned; and I certify that I know the affiants to be credible persons; that the claimant is the person he represents himself to be, and that I have no interest in this claim. [J. P.] III. Form of Declaration to be made by the Widow of a Deceased Person who has not had a Land Warrant. STATE OF 98. day of A. D. one thousand eight hundred and personally appeared before me, a Justice of the Peac [or other bfficer authorized to administer oaths for general purposes), within and for the county and State aforesaid, , in the State of in aged years, a resident of who, being duly sworn according to law, declares that she is the widow of deceased, who was a in the company commanded by Captain in the regiment of commanded by the war with Great Britain, declared by the United States, on the 18th day of June, 1812 [or other war, as the case may be]; that her said husband enlisted [or volunteered, or was drafted at on or about the day of—, A. D. for the term of and continued in actual service in said war for the term of and was honorably discharged at A. D. in a on the day of She further states that she was married to on the - day of - —, A. D. the said by one riage was on the the day of She makes this declaration for the purpose of obtaining the bounty land to which she may be entitled under the "act approved March 3, 1855;" and she further declares that she has not received or applied for bounty land under this or any other act of Congress. and that her name before her said mar -; that her said husband died at and [Claimant's Signature.] -, upon We,residents of in the State of our oaths declare that the foregoing declaration was signed and acknowledged by in our presence, and that we believe, from the appearance and statements of the applicant, tt she is the identical person she represents herself to be. [Signatures of W1resses.] The foregoing declaration and affidavit were sworn t and subscribed before me, on the day and year above writte u; and I certify that I know the affiants to be credible persons. that the claimant is the person she represents herself to be, sad that I have no interest in this claim [J. P.] [Add certificate of clerk, under seal, as in other cases.] IV. Form of Declaration to be made by the Widow of a Deceased Persin who has had a Land Warrant, and desires another. |