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[[stamp]] THE NATIONAL ARCHIVES OF THE UNITED STATES [[/stamp]] 

Bureau of REfugees, Freedmen, and Abandoned Lands.

THE UNITED STATES,
To __________Dr

[[4 Columned Table]]
| 18  |   | DOLLS. | CTS. |
|---|---|---|---|

|   | For rent of ___ at ___ County ___, occupied as a Freedmen's School from ___, 18___, to ___18 ___, inclusive, being ___ month ___ days, at ___ dollars a month |   |   |
|   | /100 Dollars,|   |   |
I CERTIFY, ON HONOR, that the above account is correct and just; that the building was occupied as stated, and was necessary for the public service.

______________________

Supt. Education State of ______
_______________________________
Bvt. Maj.-Gen., Commissioner of refugees, Freedmen, &c.

Received, at Washington, D.C., this ___ day of ___ 
from Bvt. Brig.-Gen. GEORGE W. BALLOCH, Chief Disbursing Officer, ___ dollars and ___ cents, in full of the above account,
and by Check No.___ on ___, dated ___ 18__.
[SIGNED IN DUPLICATE.]   E D ROWE

Transcription Notes:
Please read instructions, dont have to add lines on page, ... I think you read that wrong: Please include empty cells where appropriate, but do not feel the need to add empty rows.