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(Evidence of the death of the Volunteer must be filed with this claim.)

STATE OF MARYLAND BOUNTY.

State of Maryland. } Sct.

Be it remembered, That on this day of in the year eighteen hundred and   before  me the subscriber, a    in and for the  and State aforesaid, personally appeared (1)  
aged    years, who being duly sworn according to law, doth on oath, make the following declaration, in order to obtain the benefits of the provisions made by the Acts of the General Assembly of Maryland 1864, chapter 15, and amendments thereto:   that   he is the    of (2)
who was a    in Company   in the   Regiment, U.S.C.T.
   and mustered into the service of the United States aforesaid, and without any fault or negligence on his part, he died on the   day of 
  186   at (3)    and that the said (2)     died
(4)

The declarant's Post Office address is 

   therefore applies for the sum of   dollars, to which he is entitled, and hereby irrevocably constitutes and appoints HUGH L. BOND, of Baltimore, Attorney in fact, and agent to receive and receipt for the same, hereby revoking any powers of Attorney by me heretofore given.

Signature of Claimant. 

Attest [Two Witnesses.] 

Sworn to and subscribed before me the day and year first above written; and I certify that the affiant, (1) 
is known to me to be the identical person he represents self to be, and I believe that the facts stated are correct. I further certify that I have no interest in this Claim. 

At the same time personally appeared before me  and    resident citizens of  and State of Maryland, who are known to me to be persons of respectability, and entitled to full credit as witnesses, and who, being duly sworn according to law, depose and say, that they are personally well acquainted with the said (1) whose name is