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[[preprinted]]
I [[blank]], a resident of [[blank]] County, N.  C., am personallh acquainted with [[blank]], destitute [[blank]], who reside [[blank]] County, N. C., and state, to the best of my knowledge and belief [[blank]], that [[blank]] unable to maintain [[blank]], and [[blank]] no friends to attest [[blank]], and [[blank]] worthy of charity from the government.

[[blank]] [[flourish surrounding word]] SEAL [[/flourish surrounding word]]

Sworn and subscribed to before me, [[blank]], this [[blank]] day of [[blank]], 1866.

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Note-This Certificate must be signed and sworn to before some Magistrate, Justice of the Peace, or officer of the army.
[[/preprinted]]