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[3—011a.]
DECLARATION FOR INCREASE OF PENSION.

[Under the act of June 27, 1890.]

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[The pension certificate should not be forwarded with the application.] STATE OF County of On this day of

A. D. one thousand eight hundred and ninetypersonally appeared before me, a within and for the county and State aforesaid, aged years, late a member of Co.

Regiment, Vol., a resident of the of

county of

State of who, being duly sworn according to law, declares that he is a pensioner of the United States under the act of June 27, 1890, enrolled at the Pension Agency at the rate of dollars per month, by reason of partial inability to earn a support by manual labor, his pension certificate being numbered That he believes himself to be entitled to an increase of pension on account of the disabilities heretofore alleged, namely, [here insert the disabilities alleged in original and subsequent declarations]. Also on account of - [here insert the disabilities not previously alleged] incurred T [state when and where disabilities originated, and if wounds or injuries, give circumstances of incurrence). That none of said disabilities are due to vicious habits, and that they are to the best of his knowledge and belief of a permanent character,

-; that he appoints -, county of -, State of

his true and lawful attorney to prosecute his claim. That his post-office address is county of State of

[Claimant's signature:] Attest:

of

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Also personally appeared

residing at and residing at -, persons whom I certify to be respectable and entitled to credit, and [who, being by me duly sworn, say that they were present and saw

the claimant, sign his name (or make his mark) to the foregoing declaration; that they have every reason to believe, from the appearance of said claimant and their acquaintance with him, that he is the identical person he represents himself to be; and that they have no interest in the prosecution of this claim.

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[Signatures of witnesses.] Sworn to and subscribed before me this

day of

A. D., 189—; and I hereby certify that the contents of the above declaration, etc., were fully [L. S.] made known and explained to the applicant and witnesses before swear.

ing, including the words - erased, and the words - added; and that I have no interest, direct or indirect, in the prosecution of this claim.

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[Signature.]

[Official character.]

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The post-office address (naming street and number in all large cities) of the applicant, attor. ney, and witnesses should be embodied in or accompany every application, and all evidence in each claim ; and each change of residence of said parties, while communicating with the Bureau of Pensions or the pension agents, should be stated.

Pensions are, by law, exempted from any liability on account of the obligations of the pensioners, and no lien upon them can be recognized.

This declaration and any testimony in support of the allegations made therein may be executed before any officer authorized to administer oaths for general purposes in the State, city, or county where said officer resides.

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[3_022.]
DECLARATION FOR RESTORATION OF PENSION.

[Act of June 27, 1890. ]
STATE OF County of
On this

day of

-, A. D. one thousand eight hundred and ninety personally appeared before me, a within and for the county and State aforeaged years, late a member of Co.

Regiment, a resident of

county of
State of

who, being duly sworn according to law, declares:

That he was a pensioner of the United States at the rate of month under the act of June 27, 1890, until — 189—, when his pension was [reduced or discontinued] on the ground that

That he believes such action was improper for the following reasons:

That the number of his pension certificate is

That he has not been employed in the military or naval service of the United States since

18–. That he makes this deciaration for the purpose of having his pension restored at the rate of dollars per month from That he appoints

State of

his true and lawful attorney to prosecute his claim.

That his post-office address is county of State of

dollars per

of

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[Claimant's signature.]

Attest:

(1) (2)

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Also personally appeared

residing at and residing at persons whom I certify to be respectable and entitled to credit, and who, being by me duly sworn, say they were present and saw the claimant, sign his name (or make his mark) to the foregoing declaration; that they have every reason to believe, from the appearance of said claimant and their acquaintance with him of

years, respectively, that he is the identical person he represents himself to be, and that they have no interest in the prosecution of this claim.

years and

[Signatures of witnesses.] Sworn to and subscribed before me this day of --, A. D. 189–, and I

hereby certify that the contents of the above declaration, etc., were fully

made known and explained to the applicant and witnesses before swear[L. S.] ing, including the words erased, and the words added, and

that I have no interest, direct or indirect, in the prosecution of this claim.

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[Signature.]

[Official character.] To be executed before some officer of a court of record having custody of its seal, a notary public, justice of the peace, or other officer authorized to administer oaths for general purposes. If such officer is not required by law to have and use a seal, his official character, signature, and term of office must be certified by the proper State, county, or city officer under his official seal, unless such certificate has been filed in the Bureau of Pensions for general reference.

Testimony in support of allegations made in a declaration may be taken before any officer whose authority and signature are duly certified, and who shall disclaim any interest, direct or indirect, in the prosecution of the claim.

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[3012a.]

[Act of June 27, 1890. ] DECLARATION FOR WIDOW'S PENSION.

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[To be executed before a court of record or some officer thereof having custody of its seal, a notary public, or justice of the peace, whose official signature shall be verified by his official seal, and in case he has none, his signature and official character shall be certified by a clerk of a court of record, or a city or county clerk.] STATE OF County of

88: On this day of

A. D. one thousand eight hundred and ninetypersonally appeared before me, a of the within and for the county and State aforesaid aged years, a resident of the

of county of State of who, being duly sworn according to law, declares that she is the widow of

who enlisted under the name of

day of A. D. 18—, in [Here state rank, company, and regiment, if in military service, or vessel, if in Navy], and served at least ninety days in the late war of the rebellion, in the service of the United States; who was honorably discharged and died

[The cause of death need not be stated.] That the soldier was in the military or naval service of the United States except as above stated. [If any other service, it should be stated in full.] That she was married under the name of

to said day of 18–, by

at

there being no legal barrier to said marriage. [If there was a former marriage of claimant or her husband, state it here and how dissolved.] That she has not remarried since the death of the said

[Name of soldier or sailor.] That she is without other means of support than her daily labor. That names and dates of birth of all the children now living under sixteen years of age of the soldier are as follows:

born
18-

born

18born

born
18–

born 18–

born 18—. That she has heretofore applied for pension and the number of her former application is [Be careful to fill this part of the blank correctly.] That she makes this declaration for the purpose of being placed on the pension roll of the United States under the provisions of the Act of June 27, 1890. She hereby appoints

of
State of

her true and lawful attorney to prosecute her claim and receive a fee of $ That her postoffice address is county of

State of

on the

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18–

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[Claimant's signature.]

Attest:

(1)
(2)

Also personally appeared

residing at

and residing at -, persons whom I certify to be respectable and entitled to credit, and who, being by me duly sw rn, say they were present and saw claimant, sign her name (or make her mark) to the foregoing declaration; that they have every reason to believe from the appearance of said claimant and an acquaintance with her of

years and

years, respectively, that she is the identical person she represents herself to be; and that they have no interest in the prosecution of this claim.

(1)

(2) [Signatures of witnesses.]

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