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I Leathy Newsom disclose upon oath that I have [[ ]] able [[ ]] Father mother husband or relative that can furnish substance for [[ ]] no [[ ]] visions except [[ ]] and the [[ ]] real estate houses [[ ]] or other property that can be [[ ]] [[ ]] that I have (5) five children [[ ]] ending up on me for support and I further swear that I will suffer unless furnished with provision by the United States Government
Leathy Newsom
her mark
Sworn and [[ ]] me this 24th day of April A D. 1866
Jas. W. Sunderland 
[[ ]] V [[ ]] 
District of [[ ]]