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Bureau of Refugees, Freedmen, and Abandoned Lands.

THE UNITED STATES,

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

| Washington, D.C. |   |   |   |
|   | $ |   |   |
|   | /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. 

________________________
 
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,___________  dollars and  ____ cents, in full of the above account, by Check No._____  on the United States Treasury, dated 18__  . 

[SIGNED IN DUPLICATE.]
Conner Wood & McIrby