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THIS CERTIFIES,
That I have, by careful investigation, found that ________________________
has no able=bodied Father, Mother, Husband, Son or relative, that can furnish subsistence for ________; no provisions except ________; no money,Real Estate, Houses, Cotton or other property that can be converted into money; that ________ has ________ persons depending on ________ for support, and has made every effort to obtain employment without success.

And I further declare my belief that ________ will suffer unless furnished with Pro=visions, by the United States Government.

Given at ________ Ala, _______ 186

________ Alderman, ________ Wand.

[[8 columned table]]
| DATE OF ISSUE. | NO. OF PERSONS. | NO. OF DAYS. | NO. OF RATIONS. | DATE OF ISSUE. | NO. OF PERSONS. | NO. OF DAYS. | NO. OF RATIONS. |

| --- | --- | --- | --- | --- | --- | --- | --- |