General affidavit of Harriet Tubman
State of ________________, County of ________________, ss:
In the matter of _________________________________________________________________________________
ON THIS _________ day of _____________________, A. D. 18__, personally appeared before me ____________________ in and for the aforesaid County, duly authorized to administer oaths ___________________________ aged ______ years, a resident of ___________________________, in the County of _____________________________, and State of __________________________ whose Post-office address is _________________________________________________________________, aged ________ years, a resident of _______________________________, in the County of ______________________________, and State of ________________________________, whose Post-office address is ___________________________________________________________ well known to be reputable and entitled to credit, and who, being duly sworn, declared in relation to aforesaid case as follows: ____________________________________________________________________________________________________________
Note.—Affiants should state how they gain a knowledge of the facts to which they testify.)
My claim against the U.S. is for three years services as nurse and cook in hospitals, and as commander of several men (eight or nine) as scouts during the late War of the Rebellion, under directions and orders of Edwin M. Stanton Secretary of War, and of several generals.
I claim for my services above named the sum of eighteen hundred dollars. The annexed copies have recently been read over to me and are true to the best of my knowledge information and belief.
I further declare that I have
no interest in said case and am not concerned in its prosecution. and allowance.
State of New York, County of Cayuga, ss:
Sworn to and subscribed before me this day by the above named affiant , and I certify that I read said affadavit to said affiant , including the words _____________________________ _________ erased, and the words ______________________________ _________ added, and acquainted her with its contents before she executed the same. I further certify that I am in nowise interested in said case, nor am I concerned in its prosecution; and that said affiant is personally known to me and that she is a credible person .
I, _______________________________________ Clerk of the County Court in and for aforesaid County and State, do certify that ____________________________________ Esq., who has signed his name to the foregoing declaration and affidavit, was, at the time of so doing __________________________________ in and for the said County and State, duly commissioned and sworn; that all his official acts are entitled to full faith and credit, and that his signature thereunto is genuine.
Witness my hand and seal of office, this ___________ day of _______________________, 18__
[L. S.] ____________________________________
Clerk of the _________________________
☞ 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.
Late Harriet Tubman
Printed and For Sale by J. F. Shetry, Claim Blank Printer, 623 D Street, N. W., Washington, D. C.