HH

[3-017a.]

[Act of June 27, 1890.]

HH

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.]

STATE OF
On this

County of day of

sonally appeared before me, a

aged

one thousand eight hundred and ninety-
-, per-
of the
in and for the county and State
years, a resident of
county of

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

on the

day of

[here state rank, company, and regiment in military service, or vessel, if in Navy], in the service of the United States, who died at

incurred 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 num; that she makes this declaration for the purpose of being placed on the pension roll of the United States under the provisions of the

ber of her application is

act of June 27, 1890.

She hereby appoints

of

State of

attorney to prosecute her claim and receive a fee of

her true and lawful -; that her post-office

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

the

and who, being duly sworn, say that 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

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

erased, and the words

6661--15

[Signature.]

[Official character.]

The act of June 27, 1890, requires, in case of dependent mother:

1. That soldier died of a wound, injury, or disease which, under present laws, would have given him a pension.

2. That he left no wife or minor child.

3. That the mother is at present dependent on her own manual labor, or the contributions of others not legally bound, for her support.

4. All pensions under this act commence from the date of the receipt of the application in the Pension Bureau.

5. The benefits of the first section of the act of June 27, 1890, are not confined to the parents of those who served in the war of the rebellion, but extended to cases arising since the

termination of said war.

ATTORNEY:

II

[3-018a.]

[Act of June 27, 1890.]

DECLARATION FOR DEPENDENT FATHER'S PENSION.

II

[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
On this
day of
sonally appeared before me, a
aforesaid,

SS:

-, per

one thousand eight hundred and ninetyof the in and for the county and State years, resident of the of county who, being duly sworn according to law, declares that who enlisted under the name of

aged

he is the father of

on the day of

at [here state rank, company, and regiment

in military service, or vessel, if in Navy] in the service of the United States,

widow, nor child under sixteen years of age, surviving. ried to the mother of said son on the

out other present means of support than his own manual labor, or the contributions of others not legally bound for his support. That he has pension, the number of his application being

That he makes this declara

tion for the purpose of being placed on the pension roll of the United States under the provisions of the act of June 27, 1890.

attorney to prosecute his claim, and receive a fee of $

-, 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 acquaintance with him 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

(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.

[Signature.]

[Official character.]

The act of June 27, 1890, requires, in the case of dependent father:

1. That the soldier died of a wound, injury, or disease which, under present law, would have given him a pension.

2. That the soldier left no wife or minor child.

3. That the father is at PRESENT dependent on his own manual labor, or the contributions of others not legally bound for his support.

4. That all pensions under this act commence from the date of filing the applications in the Pension Bureau.

5. The benefits of the first section of the act of June 27, 1890, are not confined to the parents of those who served in the war of the rebellion, but extend to cases arising since the termination of said war.

[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.]

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

which said disa

who is at the present time suffering from
best knowledge and belief, is permanent in its character, and
said ward permanently helpless; that said ward is the legit-

bility, to -renders

and died

18—, in

at

[here state rank, company, and

-; that he left

regiment, if in the military service, or vessel, if Navy], and served at least ninety days in the war of the rebellion in the service of the United States, who was honorably discharged widow surviving him [here state date of death or of remarriage]; that the said child was born 18-; that the father was married under the name of there being no legal barrier to such marriage; that has heretofore been made for a minor's pension numbered granted; that the declarant hereby appoints

to

application

and a certificate

of true and lawful attorney to prosecute this claim and receive - post-office address is county of State of

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 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, that to be; and that they

Sworn to and subscribed before me this 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 swearing, including the words added; and that I have no interest, direct or indirect, in the prosecution of this claim.