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.