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Form of Declaration of Orphan Sisters for Any Pession. STATE [TERRITORY OR DISTRICT) OF
County of On this
personally appeared before the
A. B., a resident of in the county of and State [Territory or District] of aged years, who, being first duly sworn according to law, doth on oath make the following declaration, in order to obtain a pension under the act of July 14, 1862: That he is the legally-ap-. pointed guardian of [here give the names and ages of his ward or wards,] who the only surviving child- under six
-, his wife, and sister- of
comminded by in the
regiment of in the war of 1861, who [here state the time, place, and cause of his death.] That the brother of his said ward-, upon whom they were wholly or in part dependent for support, having left no widow, minor child or :hildren, or mother, declarant as guardian, and on behalf of his ward , refers to the accompanying evidence, and such as may be found in the department, to establish her (or their) claim under the law bove named.
He further declares that his said ward not in the re ipt of any pension under said act.
Sworn to and subscribed before me this A. D. 186—; and I hereby certify that I have no interest, direct r indirect, in the prosecution of this claim.
(Signature of judge or other officer.
Form of Surgeon's Affidavit. [If the claimant for a pension has not been examined, and the degree of his disability certified, by any army surgeon, he must produce the affidavit of two surgeons reputable in their profession, and
certified as such by the magistrate before whom their statement is sworn to, in accordance with the following form:]
(Date.) It is hereby certified that
company of in the regiment of the United States
is rendered incapable of performing the duty of a soldier, by reason of wounds or other injuries inflicted while he was actually in the service aforesaid, and in the line of his duty, viz:
By satisfactory evidence and accurate examination, it appears that on the
, being engaged at or near a place called
in the State (District or Territory) of —, he received (or contracted)* and he is thereby not only incapacitated for military duty, but, in the opinion of the undersigned, ist disabled from obtaining his subsistence from manual labor.
Sworn to and subscribed before me this
day of A.D. 186--; and I hereby certify that the said
and are known to me as surgeons in actual practice, reputable in their profession, and that I have no interest, direct or indirect, in the prosecution of this claim.
ARMY OF THE UNITED STATES.
Certificate of Disability for Discharge. [To be used, in duplicate, in all cases of discharge on account of
disability:] A. B., of Captain 's company (-) of the regiment of United States was enlisted by
* Here give a particular description of the wound, injury, or disease, and specify in what manner it has affected the applicant so as to produce disability in the degree stated.
† The blank in the last line but one is to be filled up with the proportional " degree" of disability; for example: "three-fourths," "one-half," "one-third,” &c., or, " totally," as the case may be.
in the State of is years of age,
inches high, complexion,
hair, and by occupation when enlisted - During the last two months said soldier has .been unfit for duty
days. [The company commander will here add a statement of all the facts known to him concerning the disease, or wound, or cause of disability of the soldier; the time, place, manner, and all the circumstances under which the injury occurred, or disease originated or appeared; the duty, or service, or situation of the soldier at the time the injury was received or disease contracted, or supposed to be contracted; and whatever facts may aid a judgment as to the cause,
immediate or remote, of the disability, and the circumstances attending it.]
C. D., Commanding Company. When the facts are not known to the company commander, the certificate of any officer, or affidavit of other person having such knowledge, will be appended. I certify that I have carefully examined the said
of Captain 's company, and find him incapable of performing the duties of a soldier, because of [here describe particularly the disability, wound, or discase; the extent to which it deprives him of the use of any limb or faculty, or affects his health, strength, activity, constitution, or capacity to labor or earn his subsistence. The surgeon will add, from his knowledge of the facts and circumstances, and from the evidence in the case, his professional opinion of the cause or origin of the disability.]
E. F., Surgeon.
186—, at Commanding the Post.
Note 1. When a probable case for pension, special care must be taken to state the degree of disability.
Note 2. The place where the soldier desires to be addressed may be here added. Town. County.
NɔTE.—The certificates of surgeons and commissioned officers, when
given separately, are required to conform, in substance, to the requirements of the above form. A due observance of this will save applicants much trouble and expense, and greatly hasten action on their applications. This is especially true, if these two certificates accompany the declaration when sent to the Pension Office.
INSTRUCTIONS AND FORMS
ACT OF JULY 14, 1862.
Joint Resolution to grant pensions to masters and officers upon the gun
boats in the service of the United States.
Resolved by the Senate and House of Representatives of the United States of America in Congress assembled, That the masters serving on board of gunboats employed in the service of the United States shall be entitled to all the benefits, including bounty and pension, provided for in an act entitled “An act to grant pensions,” passed during the present session of Congress, and the widows, mothers, and heirs of such officers shall be entitled to all the benefits of said act.
Approved July 16, 1862.
Under the act of Congress approved July 14, 1862, pensions are granted to the following classes of per
I. INVALIDS, disabled since March 4, 1861, in the military or naval service of the United States, in the line of duty.
II. Widows of officers, soldiers, or seamen, dying of wounds received or of disease contracted in the military or naval service, as above.
III. Children, under sixteen years of age, of such deceased persons, if there is no widow surviving, or from the time of the widow's re-marriage.
IV. MOTIIERS (who have no husband living) of officers, soldiers, or seamen, deceased as aforesaid, provided the latter have left neither widow nor children under sixteen years of age; and provided, also, that the mother was dependent, wholly or in part, upon the deceased for support.
V. SISTERS, under sixteen years of age, of such deceased persons, dependent on the latter, wholly or in part, for support, provided there are no rightful claimants of either of the three last preceding classes.
The rates of pension to the several classes and grades are distinctly set forth in the first section of the act, a copy of which is herewith published. Only one full pension in any case will be allowed to the relatives of a deceased officer, soldier, or seaman, and in order of precedence as set forth above. When more than one minor child or orphan sister thus becomes entitled to pension, the same must be divided equally between them.
Invalid pensions, under this law, will commence from the date of the pensioner's discharge from service, provided application is made within one year thereafter. If the claim is not made until a later date, the pension will commence from the time of the application. Pensions of widows and minors will commence from the death of the officer, soldier, or seaman, on whose service the claim is based.