quaintance with him, that he is the identical person he represents himself to be; and they further state that they have no interest in the prosecution of this claim.

Sworn to and subscribed before me this

(Signatures of witnesses.)

day of

A. D. 186—; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

Applicant's post office address:

(Signature of judge or other officer.)

B.

Form of Declaration for obtaining a Widow's Navy Pension.

STATE [TERRITORY OR DISTRICT] OF

}

peared before me

of the

in the county of

aged

A. B., a resident of

and State [Territory or District] of

years, who, being first duly sworn according to law,

doth on her oath make the following declaration, in order to obtain the benefits of the provision made by the act of Congress approved July 14, 1862, granting pensions: That she is the widow of

who was a [here state decedent's service] who [here specify the time, place, and cause of death.] She further declares that she was married to the said

on the

day of

in

died on

; that her husband, the aforesaid

the yearthe day above mentioned, and that she has remained a widow ever since that period, (or if she has re-married and again become a widow, the fact must be stated,) as will more fully appear by reference to the proof hereto annexed. The personal description of the said her deceased husband, is as follows: [here state his age, height, complexion, occupation, &c.] She also declares that she has not in any manner been engaged in, or aided or abetted, the rebellion in the United States.

ty, city, or town,) person whom I certify to be respectable and enti

tled to credit, and who, being by me duly sworn, say that they were present and saw sign her name (or make her mark) to the foregoing declaration; and they further swear that they have every reason to believe, from the appearance of the applicant and their acquaintance with her, that she is the identical person she represents herself to be, and that they have no interest in the prosecution of this claim.

(Signature of witnesses.)

day of

Sworn to and subscribed before me this A. D. 186-; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

Applicant's post office address:

(Signature of judge or other officer.)

C.

Form of Declaration for Minor Children in order to obtain Navy

peared before me

of the

in the county of aged

A. B., a resident of ·

and State [Territory or District] of

years, who being first duly sworn according to law, doth on oath make the following declaration, as guardian of the minor child of deceased, in order to obtain the benefits of the provision made by the act of Congress, approved July 14, 1862, granting pensions to minor children, under sixteen years of age, of deceased officers and seamen; that he is the guardian of

[naming the minor child or children, his ward or wards,] whose father was a — [here state decedent's service;] and that the

He further declares that the parents of his said ward- were mar

as follows:

ried at by

on the

day of

in the year

(Guardian's signature.)

Sworn to and subscribed on the day and year first above written, before ; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

(Signature of judge or other officer.)

D.

Form of declaration for Mother's application for Navy Pension.

STATE [TERRITORY OR DISTRICT] OF

On this peared before the

County of
day of

} s

SS:

of the

in the county of

aged

A. B., a resident of

and State [Territory or District] of

years, who, being first duly sworn according to law, doth on her oath make the following declaration, in order to obtain the benefits of the provisions made by the act of Congress approved July 14, 1862, granting pensions: That she is the widow of

[here state decedent's [here state the time,

She further declares that her said son, upon whom she was wholly or in part dependent for support, having left no widow or minor child under sixteen years of age surviving, declarant makes this application for a pension under the above-mentioned act, and refers to the evidence filed herewith, and that in the proper department, to establish her claim.

She also declares that she has not, in any way, been engaged in, or aided or abetted, the rebellion in the United States; that she is not in the receipt of a pension under the 2d section of the act above mentioned, or under any other act, nor has she again married since the death of her son, the said

Also, personally appeared

(Declarant's signature.)

and

residents of

(county, city, o' town,) 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 sign her name (or make her mark) to the foregoing declaration; and they further swear that they have every reason to believe, from the appearance of the applicant and their acquaintance with her, that she is the identical person she rep

resents herself to be.

(Signature of witnesses.)

day of

Sworn to and subscribed before me this A. D. 186-; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

Applicant's post office address:

(Signature of judge or other officer.)

E.

Form of Declaration of Orphan Sisters for Navy Pension.

STATE [TERRITORY OR DISTRICT] OF

County of
day of

On this peared before the

SS:

of the

in the county of

aged

A. B., a resident of

and State [Territory or District] of

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-appointed guardian of [here give the names and ages of his ward or wards,] who the only surviving child- under sixteen years of age, of

2

and

-, his wife, and sister- of who was a [here state decedent's services and personal description] 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 children, 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 above named.

He further declares that his said ward of any pension under said act.

not in the receipt

(Guardian's signature.)

Sworn to and subscribed before me this

day of

A. D. 186-; and I hereby certify that I have no interest, direct or indirect, in the prosecution of this claim.

(Signature of judge or other officer.)

Applicant's post office address:

F.

Form of Surgeons' Affidavit.

[If the claimant for a pension has not been examined, and the degree of his disability certified, before his discharge, by a navy surgeon, and if the certificate of a navy surgeon or a board of survey is not obtainable, on satisfactory explanation of this fact, he may 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

who was a

in the

naval service of the United States, [here state the vessel or station on which applicant was engaged, and his particular service,] is suffering from* and he is thereby not only incapacitated for

dis

naval duty, but, in the opinion of the undersigned, is† abled from obtaining his subsistence from manual labor. And we further certify that upon satisfactory evidence and after accurate examination, we believe the said disability was incurred in the naval service of the United States and in the line of duty.

day of

and

Sworn to and subscribed before me this A. D. 186; and I hereby certify that the said 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.

(Magistrate's signature.)

* 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.

†This blank 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.