[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.]

on the day of

aged of who, being duly sworn according to law, declares who enlisted under the name of at —, A. D. 18—, in

that she is the widow of

[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

on the

day of

18-, by

to said

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-.

sion and the number of her

part of the blank correctly.]

18. That she has heretofore applied for penformer application is

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

ful attorney to prosecute her claim and receive a fee of $

her true and lawThat her post

[Claimant's signature.]

Attest:

(1)
(2)

Also personally appeared

residing at

residing at

and

-, persons whom I certify to be respectable and entitled to credit,

and who, being by me duly sworn, 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, respectively, that she is the identical person she represents herself to be; and that they have no interest in the prosecution of this claim.

years and

(1)

(2)

[Signatures of witnesses.]

day of

Sworn to and subscribed before me this , A. D. 18-; and I hereby certify that the contents of the above declaration, etc., were fully made known and explained to the applicant and witnesses before swearing, including the words erased and the words added; and that I have no interest, direct or indirect, in the prosecution of this claim.

The act of June 27, 1890, requires, in widow's case:

[Official character.]

1. That the soldier served at least ninety days in the war of the rebellion and was honorably discharged.

2. Proof of soldier's death (death cause need not have been due to army service).

3. That widow is "without other means of support than her daily labor."

4. That widow was married to soldier prior to June 27, 1890, date of the act.

5. That all pensions under this act commence from date of receipt of application in Pension Bureau.

[Signature.]

FF

[3-015a.]
[Act of June 27, 1890.]

FF

DECLARATION FOR CHILDREN UNDER SIXTEEN YEARS OF AGE.

[To be executed before any officer authorized to administer oaths for general purposes in the State, city, or county where said officer resides. If such officer has a seal and uses it upon such paper, no certificate of a county clerk or prothonotary or clerk of a court shall be necessary; but when no seal is used by the officer before whom the declaration is executed, then a clerk of a court of record or a county or city clerk shall affix his official seal thereto, and shall certify to the signature and official character of said officer.]

ing to law, makes the following declaration in order to obtain the pension provided by act of Congress approved June 27, 1890: That is the legal guardian of who enlisted under the name of

,

legitimate child- of

at

on the

day of

18-, in

That he left

[here state rank, company, and regiment, if in the military service, or vessel, if in Navy] and served at least ninety days in the war of the rebellion in the service of the United States; who was honorably discharged and died widow [here state date of death or of remarriage]. That the names and dates of birth of all the surviving children of the soldier under sixteen years of age are as follows:

surviving him

and lawful attorney to prosecute this claim and receive a fee of $post-office address is

That

-, county of

State of

-, persons whom I certify to be respectable and entitled to credit, and who, being duly sworn, say that they were present and saw claimant, sign -name (or make mark) to the foregoing declaration; that they have every reason to believe, from the appearance of said claimant and their acquaintance with years, respectively, to be, and that they have no

day of

Sworn to and subscribed before me this A. D. 18-, and I hereby certify that the contents of the above declaration, etc., were fully made known and explained to the applicant and witnesses before swearing, including the words erased and the words added, and that I have no interest, direct or indirect, in the prosecution of this claim.

The act of June 27, 1890, requires that in minor children's cases:

[Official character.]

1. That the soldier served at least ninety days in the war of the rebellion and was honorably discharged.

2. Proof of soldier's death [cause need not have been due to army service], his marriage to

mother, and proof of her death or divestment of title.

[Signature.]