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Bureau of Refugees, Freedmen, and Abandoned Lands.

The United States,

To .............. Dr.
[[4 Columned Table]]
| 18  |   | Dolls. | Cts. | 
| --- | --- | --- | --- |

| Washington, D.C. | 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, |   |   | 

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

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 
Approved and ordered paid. 
__________________________________________________
Bvt. Maj.-Gen., Commissioner of Refugees, Freedmen &c.

Received, at Washington, D.C., this ____ day of ___ 18__ , from Bvt. Brig.-Gen. GEORGE W. BALLOCH, Chief Disbursing Officer,___________  dollars and  ____ cents, in full of the above account, by Check No._____  on _____, dated 18__  . 

[SIGNED IN DUPLICATE.]
F. A. M. Shaver