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Form for Office Rect
Bureau of Refugees, Freedmen, and Abandoned Lands.
The United States, 
To James T Lewis D&.

[[4 columned table]]
|1869 |   |Dolls.|Cts.|
|---|---|---|---|
|April 30 | For rent of building (or rooms) occupied as Offices by the Supt. of Education and Asst. Disbursing Officer, for the payment of Bounties, Bureau R.F. and A Lands at Richmond Va. from April 1" to April 30" 1869 - inclusive - one month at Seventy five dollars a month| 75| 00|
|Washington, D.C.| $ |   |   |
|   |Seventy five 00/1-- Dollars,|   |   |
[[\4 columned table]]

I certify, on honor, that the above account is correct and just; that the [[strikethrough]] services were rendered [[\strikethrough]] building was occupied as stated, and [[strikethrough]] were [[\strikethrough]] was necessary for the public service.

R.M. Manly
Supt. of Education State of Virginia 
Approved, and ordered paid.
Bvt. Maj.-Gen., U.S.A., Commissioner,
Received, at Washington, D.C., this _ _ _ day of _ _ _ 18  , from Bvt. Brig.-Gen. George W. Balloch, Chief Disbursing Officer, Seventy five Dollars and -- Cents, in full of the above account, by Check No. _ _ _ on the United States Treasury, dated _ _ _ 18  . 
[Signed in duplicate]
James T. Lewis