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[3—012a.]

[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

SS: On this - day of

A. D. one thousand eight hundred and ninety-personally 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

at on the 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 on the 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
born
18–

born
18

born 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

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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 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.

(1)

(2) [Signatures of witnesses.

years and

2

Sworn to and subscribed before me this day of

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.

[Signature.]

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[3—015a.]

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[Act of June 27, 1890. ]

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DECLARATION FOR CHILDREN UNDER SIXTEEN YEARS OF AGE.

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[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.] STATE OF County of

SS: On this day of A. D. one thousand eight hundred and ninety-personally appeared before me, a of the in and for the county and State aforesaid,

years, who, being duly sworn accord- . 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 legitimate child- of

who enlisted under the name of at

day of 18—, in [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

That he left widow surviving him [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:

born

18% born

18%. born

18— born

18– born

18– born

18% That the father was married under the name of

to there being no legal barrier to such marriage. That the declarant hereby appoints

of

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

county of State 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 duly sworn, say that they were present and saw

the 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

for

years, respectively, that is the identical person

represents

to be, and that they have no interest in the prosecution of this claim.

(1)

(2) [Signature of witnesses.]

years and

Sworn to and subscribed before me this

day of

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.

[Signature.]

[Official character.] The act of June 27, 1890, requires that in minor children's cases:

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.

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[3--017a.]

[Act of June 27, 1890.]

DECLARATION FOR DEPENDENT MOTHER'S PENSION.

[ To be executed before a court of record or some officer thereof having custody of its seal, a notary public or a 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.]

SS:

9

-, aged

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STATE OF

County of On this day of

one thousand eight hundred and ninety- personally appeared before me, a of the in and for the county and State aforesaid,

years, a resident of

-, county of State of who, being duly sworn according to law, declares that she is the mother of who enlisted under the name of

at on the

day of — 18–, in [here state rank, company, and regiment in military service, or vessel, if in Navy), in the service of the United States, who died at

on the
day of
18—, from the effects of

incurred at on the day of

18—; that said son left neither a widow, nor child under sixteen years of age, surviving; that she is without other present means of support than her own manual labor or the contributions of others not legally bound for her support; that she has applied for a pension; the number of her 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 her true and lawful attorney to prosecute her claim and receive a fee of $- ; that her post-office address is county of State of

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[Claimant's signature.)

Attest:

(1) (2)

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years and

Also personally appeared

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

the 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.

(1)

(2)

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

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[Signature.]

[Official character.]

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