Revolutionary War Pension and Bounty Land Warrant Application File W 8278, John Carlton, Mass.

SERVICE
NUMBER
Mass.
Carlton, John Moore, Ann
W 8278
B.L.Wk. 9498-160-55-
(Former widow)
CONTENTS

14.061 R
District of Maine
John Carlton
of Frankfort in the state of Me who was a Private in the regiment commanded by Colonel Nason of the Meapachemett line, for the term of Three years
Inscribed on the Roll of District of Maine at the rate of 8 Dollars per month, to commence on the 7 th of April 1818
Certificate of Pension issued the 17 of Decr 1818 and sent to M c Kinley Esq r Bangor Me
Arrears to 4th of Mar. 1819  87.43
Semi-ann. all'ce ending Sep. 1819  48.00
10 Mo. 24 4 30 31
$133.43
{ Revolutionary claim, } { Act 18th March, 1818. }
Not entitled
Reinstated
July 6. 1821 and notice given R. C. Vose Esq r
Application and July 12 1820 R. C. Vose Esq r Augusta Me

John Carlton
Private
Col Nison's Regiment
1778 - 2 years & 10 months
_____
on roll as stated
Admitted

I John Carlton of Frankfort in the County of Hancock, Gentleman do hereby testify & say: that I enlisted into the service of the United States in Capt. John Spurr's Company & Col. Nicholson's  Nixon's Reg. t on or about the first day of Feb. y 1778. for the term of three years; I served two years ten months & nineteen days when I received an honorable discharge; which was afterwards burnt with my dwelling house
I am now under reduced circumstances and need the assistance of my country for support; I hereby relinquish all claim to any previous Pension on account of my said services. Witness my hand —
John Carlton
Commonwealth of Massachusetts.
ENOBSHOT, ss.
ON the 7 th day of April — A. D. 1818, before me the subscriber, one of the Judges of the Third Eastern Circuit, of the Court of Common Pleas, in said Commonwealth, including the Counties of Hancock, Washington and Penobscot: Personally appeared John Carlton who, being by me first duly sworn according to law, on his oath made the statement and declaration by him subscribed, and hereto annexed, in order to obtain the provision made by the late act of Congress, entitled "An Act to provide for certain persons engaged in the land and naval service of the United States, in the revolutionary war."
And thereupon, I the said Judge do certify that I am satisfied the said John Carlton did serve in the revolutionary war, as stated in his said declaration, against the common enemy, and that he has made it appear to me, that he is in reduced circumstances, and stands in need of the assistance of his country for support.
Which proceedings and the testimony annexed, being all he has been able to produce, I now transmit to the Secretary, for the department of War, pursuant to the directions of the aforementioned act of Congress.
IN testimony whereof, I have hereunto set my name and caused the seal of said Court to be hereto affixed M c Kinsley Esquire, Judge of the Court as aforesaid.

John Carleton
No 14. 061.
ms 160.
17th Aug 1819
Not Entitled
Sep 1819
Robert C. Vose, Augusta Maine
John Cady Albert John Danti Chas 6966. Museum National Westph

State of Maine.
327
Copy
KENNEBEC COUNTY, ss.
ON this Sixth day of June, 1820, personally appeared before in open court before Justice of the Circuit Court of Common Pleas, for the Counties of Lincoln, Kennebec and Somerset, being a Court of Record for said Counties, proceeding according to the course of the common law, having original jurisdiction, unlimited in amount, keeping a record of their proceedings, and having the power of fine and imprisonment, John Carlton aged Fifty nine years, resident in Frankfort in the County of Hancock now at Augusta within said Circuit, who being first duly sworn according to law, doth, on his oath, declare that he served in the Revolutionary war as follows, viz. in the Company commanded by Captain Spurr and Regiment commanded by Colonel Nixon of the line of the State of Massachusetts upon the Continental Establishment, for the period of three years, wanting six weeks.
that his original declaration was made before Judge Kinsley on the Seventh day of April 1818; that he is now on the Maine Roll, and that his pension certificate is numbered 14061. And I, the said John Carlton do further solemnly swear, that I was a resident citizen of the United States, on the eighteenth day of March, one thousand eight hundred and eighteen; and that I have not, since that time, by gift, sale, or in any manner whatever, disposed of my property, or any part thereof, with intent thereby so to diminish it as to bring myself within the provisions of an act of Congress, entitled, "An Act to provide for certain persons engaged in the land and naval service of the United States, in the Revolutionary War," passed on the eighteenth day of March, one thousand eight hundred and eighteen; and that I have not, nor has any person in trust for me, any property or securities, contracts or debts, due to me; nor have I any income, other than what is contained in the schedule hereto annexed, and by me subscribed.
John Carlton
The following is a Schedule of my whole Estate and income, necessary clothing and bedding excepted, viz: The right in equity of  to a certain eighty two acres of land in said Frankfort with a small unfinished house thereon which right is of the value of fifty dollars, one old horse of the value of fifteen dollars, two cows of the value of thirty dollars, one yoke of steers three years old of the value of thirty dollars, one calf of the value of three dollars, four sheep and four lambs of the value of eight dollars, one sow and seven pigs of the value of twelve dollars, old household stuff besides necessary bedding not exceeding eight dollars in value, one wooden clock worth three dollars, implements of husbandry, of the value of three three dollars, and seventy five cents, one old sleigh and harness worth five dollars. debts due to me that can be collected not exceeding three dollars and I owe on the mortgage aforesaid three hundred dollars, and I owe besides two hundred and thirty dollars.

My income from the above property deduct- ing the interest I have to pay, does not exceed five Dollars a year. I am by occupation a farmer, but from age and infirmity, being Rheumatic and trouble with the gravel unable to do very little. My family at home consists of myself, wife Hannah aged sixty one years, who is infirm often laid up with sickness and cannot do much. My son James aged Twenty seven years who is a cripple who having a bad knee and un- able to earn his living, my daughter Mary aged twenty three subject to the Phthisic, and my daughter Amy aged fifteen who has had her right hip dislocated for twelve years, which has occasioned her right thigh and leg partially to perish and she is unable to go without crutches. Except the foregoing and my necessary clothing & bedding, I have no property or income whatsoever.
John Carlton both the oath and schedule Subscribed, sworn to and declared on the sixth day of June 1820 before me
Nathaniel Weston Jr 6166 Plover
True Copy Attest J. M. Davis Clk.
Robert D. Root, Augusta Maine
Oct 1819
Robt D. Root
14th Aug 1819
with $160.
Inst. 621
John Carlton
327

454411 Waime
Ann Moore, formerly widow of John Carlton. Nah who served in the Revolution-
ary war, as a private
Inscribed on the Roll at the rate of 96. Dollars 00 Cents per annum, to commence on the 3d February, 1853.
Certificate of Pension issued 3 rd day of Oct r 1854.
and sent to John J Dickinson Present.
Recorded on Roll of Pensioners under act February 3, 1853, Page 7. Vol. a
1854

Declaration of Widow Mrs. Ann Moore for Pension act of Feb 3, 1853
Filed by Geo. T. Dickinson Present Sept 28/54

State of Maine } ss County of Penobscot }
On this seventeenth day of December A D 1853, personally appear- ed before me the undersigned a Justice of the Peace, with and for the County & to State, aforesaid Mrs Ann Moore a resident of the Town of Plymouth County and State aforesaid aged 67 years, who first being duly sworn according to Law, doth on her oath declare and make the following de- claration in order to obtain the bene- fits of the Provisions made by the act of Congress passed February 3 d A D 1853, granting pensions to the widows of persons who served du- ring the "Revolutionary War,"
That she is the widow of John Carlton who was a private soldier in the Revolutionary War, and drew a pension of ninety six dollars per year during his life time, which sum was drawn

and said to him at the Portland Maine agency, she can not state definitely to what Regiment or Company her husband was attached, but she hereby refers to the papers, & Documents now on file in the Pension office; & on which her pension was originally allowed, as showing all the facts in relation to her said Service, she further declares that she was legally married to the said
John Carlton - on the twentieth day of June in the year of our Lord one thousand eight hundred & thirty one by Rev Mr Trask of Hudson, Maine, at the house of James Walloway. That her maiden name was Ann Allen that her said husband she afterwards
John Carlton died at Palermotte on the eleventh day of June one thousand eight hundred and thirty nine and that she is now, was then, on the third day of Feb - AD 1853, the date of the passage of said act in Medaw, That after the said John Carlton's death, to wit on the 31st day of Octob AD 1845 she was married to Ebenezer Moore at St Albans Me - by Esqr E. Stearns and that said Ebenezer,

Moore dies on the 17th day of October AD 1846 and that she is now at the date of the act of Congress herein, as aforesaid a widow, said Ebenezer knows that in St Albans, Me, my Witness, G. P. Brown Ann X Moore Samuel Putnam mark
Subscribed and sworn to, on the day & year first above written by Ann Moore to me well known and I certify that said Ann Moore resides between Twenty & thirty miles from any Court of Records or the residence of any Judge of a Court of Records and that in my opinion she is unable by reason of bodily infirmity to travel or be annoyed to any Court of Records, or the residence of any Judge of a Court of Records to make this declaration, and that it would be very difficult to procure the at- tendance of any Judge of a Court of Records at her residence to take said application - I would sub- ject her to more expense than she is able to pay That I have known her above four years and she appears to be of the age she has stated and that I have no interest in this case & am not concerned in its disposition
(Samuel Putnam) For her of the Peace,

Act March 3. 1855
81465- apl 19/1855
Ann Moose with John Carlton
Private Champlain Regt
Map 1998 Rev War
Rev Pensioner Pension no. 4544. Act July 3. 1833 Me - July 53-4544
Boynton
Ad. 160ac's Nov 9/55
Dodge
Chas P. Brown Bangor Me
Vol. 61-5.

416 H465-
application of
Ann None
Rev. Bowly Larp
act of March 3 d 1855
Charles P. Brown Sty
Bangor, Maine

STATE OF MAINE. County of Penobscot } ss.
On this thirteenth day of March A. D. one thousand eight hundred and fifty five , personally appeared before me, a Justice of the Peace, within and for the County and State aforesaid, Ann Moore aged sixty eight years, a resident of Detroit in the State of Maine, who being duly sworn according to law, declares that she is the widow of John Carlton deceased, who was a private in the company commanded by Capt.
In the Revoir having been as appears by the declaration below
that her husband enlisted on or about _____ for the term of _____ for the term of _____ the _____ day of _____
A. D. _____ and continued in actual service in said War and was honorably discharged on or about _____ A. D. _____ as will appear by
That said John Carlton was a pensioner for his services at the rate of fifty dollars per year, That she has heretofore applied for the pension as his widow & that, that on the third day of October A.D. 1854 she was duly inscribed on the Pension Rolls at the rate of fifty dollars per year - under the act of Feb 3 d 1853 pension certificate is No 21,544 she refers to her papers now on file in that case for a full statement, & especially for her marriage & her husband's death  her marriage & her husband's death here, she is now at the Waltham  her home
She further states that she was married to the said John Carlton as in full in her  on the  Declaration day of April  1854 A. D. before her said marriage was  by one  and that her name  died at  that her said husband  on the  day of _____
and that she is still a widow. & her pension is continued to her
She further declares that neither she, nor her said husband were ever entitled to, or have they received, Bounty Land under this or any other act of Congress. & never made any application for the same. She makes this declaration, for the purpose of obtaining the Bounty Land to which she may be entitled, under the Act of Congress passed March 3 d A.D. 1855
granting Bounty
Lands to certain officers and soldiers, and their heirs or widows, who have been engaged in the Military service of the United States.
Witness Jacob Brooks  Ann Moore
Subscribed and sworn to, before me, the day and year first above written, and I hereby certify that I believe the said Ann Moore to be the widow of the soldier above named, and that she appears to be of the age above written, and that I have no interest whatever, of any kind or description in the Warrant that may be issued upon the foregoing application.
Saml. Putnam
Justice of the Peace.

STATE OF MAINE, on oath depose and say that my presence, and that he died at on the day of
of in the personally acquainted with deceased, who was the husband of who subscribed the foregoing declaration, in in the State of A. D.
STATE OF MAINE, County of Personally appeared the above named the truth of the foregoing affidavit by Before me,
ss. A. D. and made oath to signed in my presence.
Justice of the Peace.
We Jacob Brooks, and Rhoda Brooks,
both of Skowhegan in the STATE OF MAINE, on oath depose and say, that we were personally acquainted with Ann Moore who subscribed the foregoing declaration in our presence and have known her ten years, or upwards and that we personally know the parties in the life of the husband, and know them to live together as husband and wife, and to be so reputed, and that she still remains the widow of said  Brooks deceased John Gulliver who served as set forth. & we know from personal knowledge that she is the identical person who represents herself to be,
Jacob Brooks Rhoda Brooks
STATE OF MAINE, County of Penobscot ss. March 13 A. D. 1855
Personally appeared the above named Jacob Brooks, & Rhoda Brooks , and made oath to the truth of the foregoing affidavit, by them signed, in my presence. & I certify That I know said Jacob Brooks to be a credible witness Before me, Jacob Brooks, & Rhoda Brooks Justice of the Peace  Justice of the Peace  That I know no reason in this case & am not concerned in its prosecution & that the claimant is the person who represents herself to be  Saml Batman  Justice of the Peace
STATE OF MAINE, County of Penobscot ss.
I, NATHAN WESTON, Jr., Clerk of all the Judicial Courts in said County, hereby certify, that Saml Batman Esquire, is an acting JUSTICE OF THE PEACE in and for said County, as appears by the foregoing certificates, that he is duly qualified to act as such; and that the signatures purporting to be his, are genuine.
IN TESTIMONY WHEREOF, I have hereunto set my Hand and affixed the Seal of the SUPREME JUDICIAL COURT for said State, this fourteenth day of April in the year of our Lord one thousand eight hundred and fifty-five Nathan Weston Jr.
Clerk.

1930 Apr 21. Photo mailed to Edw. A. Gould. See Joel Adams, W 23402. A.P.T.
Rev WIDOW, &c.
File No. _____
8278
Ann Moore
formerly Wid.
John Carlton
Print Rev War
Act: _____
Feby 3 d
1855
Index:—Vol. _____
116
Page _____
60
[Arrangement of 1870.]

No. 81465-
ACT OF MARCH 3, 1855.
Received Apr. 19 th , 1875-
Mr. Carlton Pri. Decd.
Nixon's Regt.
Map. Line
Rev. War
9498-160 5-5-
Chas. P. Beaton
Bangor
Me.

9498
S
160 Ares

Amount of property $160.75
Age 59. Served 3 years.
Farmer, unable to labor much. wife 61. infirm. James, aged 27 - a Cripple & unable to labor. Mary 23 - Anna 15. her hip dislocated 12 years since , & the right thigh & leg, partially perished.
Pon
unstable

Pension Office
Sept 30/54.
Sir: 11 June '39
Please report time of last payment to, or death of within named pensioner
Yours &c.
R. J. Atkinson Esq. and Present
S. Dale for Compt.
John Carlton died 11 June 1839. pd in full
Relr J. M. M.
Auditor

Quitt
327
State of Maine.
I John Davis Clerk, for the County of Wennebec of the Circuit Court of Common Pleas for the second Eastern Circuit, embracing the counties of Lincoln, Ken- nebec and Somerset, do hereby certify, that the foregoing oath and the Schedule thereto annexed, are truly copied from the record of the said Court ; and that the original was exhibited in open Court ; and I do further certify that it is the opinion of the said Court that the total amount in value of the property exhibited in the aforesaid Schedule, including debts due to the declarant therein stated, is One hundred fifty dollars and seventy five cents ; and deducting therefrom the amount of what the declarant owes, as set forth in said Schedule, the value of said property in the opinion of said Court, is Nothing  dollars and  cents .
In testimony whereof, I have hereunto set my hand and affixed the seal of the said Court, on this twentieth day of June 1820.
John Davis Clerk of said Court for the County of Wennebec

Breit in the case of Mrs Ann Moore widow of John Carlton Penobscot County and State of Maine act of February 3 rd 1853
Claim, ("original," or "for increase.") Allowed $96 per annum to commence February 3-1853
Proof exhibited, (if original.)
Documentary & Pard.
Is it documentary, traditional, or supported by rolls? If either, state the substance.
Husband a pensioner under act of March 18 1818 at $96 per annum to commence February & paid to his death 11 June 1839
(If for increase.)
Has additional evidence been filed since the admission of the claim? If so, what?
Marriage proved by five credible witnesses (no record)
Death of pensioner proved by Aud. rep.
Identity & widowhood shown by four credible witnesses
Papers properly prepared
Name and residence of Agent
John P. Dickinson Esq.
Present
Examining Clerk.
L. Lelray

John Carlton
327
17 Aug 1819
D Nashville

War Department, No 14. 061.
PENSION OFFICE,
11th July - 1820
SIR,
You are hereby informed that the Secretary of War does not, on account of the amount of your property, consider you entitled to a Pension under the Acts of the 18th March, 1818, and 1st May, 1820; and has, therefore, directed your name to be stricken from the Pension List.
I am, respectfully,
Your obedient servant,
J. L. Edwards
To Mr. John Carlton,
Frankfort,
Maine.

State of Maine.
PENOBSCOT, ss.
I, NATHAN WESTON, Jr., CLERK OF ALL THE JUDICIAL COURTS in said County, certify that
Samuel Butman
Esquire, is
an acting Justice of the Peace, in and for said County, as appears by the paper hereto annexed, that he is duly commissioned and qualified to act as such;
and that the signature to the annexed paper purporting to be his is genuine. and I further certify, that the aforesaid Samuel Butman is at this time President of the Senate of the State of Maine, which Office he has held since the month of January last past.
In Testimony Whereof, I have hereunto set my Hand, and affixed the Seal of the SUPREME JUDICIAL COURT for said State, this seventeenth day of December, in the year of our Lord one thousand eight hundred and fifty three.
Nathan Weston Jr.
Clerk.
House of Representatives - July 27, 1854 -
Hon. Saml. Butman, whose name appears in the foregoing Certificate, is a gentleman of the highest respectability & moral worth, & his statements are entitled to the fullest credit. He was, at the date of said Certificate, President of the Senate of Maine, & for several years, represented the Penobscot district in the Congress of the United States. J. Washburn M.P. from Maine.

State of Maine County of Penobscot ss
On this 20th day of June AD 1834 before me the subscriber, a Justice of the Peace in & for the County & State aforesaid personally came Jacob Brooks of Plymouth in said County aged 52 years who first having been duly sworn according to law on his oath declares that he is well acquainted with Widow Ann Moore of said Plym- outh & has known her for thirty years last past, That he was not present at her marriage with John Carlton formerly of Palermo Maine, but he was well ac- quainted with said John Carlton in his life time, & knows that he drew a pension of $96 per year for his services as a soldier of the Revolu- tionary war, up to his death in the year A.D. 1839 - That he knew said Ann before her marriage to said John Carlton, & knows that from June AD 1831 up to the time of his death as aforesaid they lived & cohabitated together in all respects as husband & wife

That he has known Ann ever since the death of her John Carlton -
That in the year AD 1845 Ann was married to Mr Ebenezer Moore of St Albans Maine, & knew & cohabited with him as his wife until the next year AD 1846 when said Ebenezer Moore died He knows that since said Moore's death Ann has remained a widow, & is now a widow - That she has lived a part of the time in Deborah's house in her family & he knows all the above facts absolutely. That he is not interested in this case in any other way or manner,
Jacob Brooks
Subscribed & sworn to the day & year first above written by Jacob Brooks. To me well known as a credible & disinterested witness & I certify that I have no inter- est in this case & am not concerned in its success.
Beth in Church P. Brown Notary Public

deposition of Mrs Sarah Bragg of Vasselboro—

State of Maine County of Kennebec
On this Twelfth day of September AD 1834 personally appeared before the subscriber a Justice of the Peace within & for the County & State aforesaid Sarah Bragg of Vassalboro in said County aged fortythree years who first having been duly sworn according to law on her oath declares that she is well acquainted with Mrs Ann Moore, now of Plymouth, Penobscot County Maine, & has known her all her life - That the maiden name of said Ann Moore was Ann Allen - That she, the deponent, was well acquainted with John Carlton who was a Revolutionary soldier - and drew a pension from the United States of ninety six dollars a year, That she knows that said John Carlton died in
• Palermo, Maine on the Eleventh day of June, • AD 1839, and she also knows that said Ann, was legally married to said John Carlton on the Twentieth day of June AD 1831, at the residence of Mr James Stearns Holloway in Mindanao Maine by

The Reverend Mr Trask a minister of the gospel, That said affiant was present witnessed the said marriage, & also knows that said John Carlton & Ann his wife lived together as husband & wife until his death on the eleventh of June 1839 — said affiant also knows that said Ann Carlton afterwards about the 7th day of October AD 1845, was married to Eben- ezer Moore of St Albans — Maine, and lived with said Moore until his death which took place in the month of Octo- ber AD 1846 — She knows that said Ann Moore has not been married since the death of her last husband, Ebenezer Moore, at the time aforesaid, That she has remained a widow ever since that time, & that she is now a widow — Sarah A. Bragg witnessed Joseph Bauman
Subscribed & sworn to the day & year first above written, before me, & I certify that said Sarah A Bragg is a disinterested & credible witness, and that I have no interest in this case & am not concerned in the present testimony — — Joseph Bauman — Justice of the Peace

Deposition of

State of Maine, County of Kennebec,
On this the fourteenth day of September A D 1854 personally appeared before the subscriber a Justice of the Peace within & for the County & State aforesaid Jonas Proctor W. H. Proctor of Windsor in said County aged sixty five years who first having been duly sworn accor- -ding to law, on his oath declares that he is well acquainted with Mrs Ann Moore now of Plymouth in said State & that he has been acquainted with her for thirty years. That he was well acquaint- -ed with John Carlton of Palermo, in his life time, & knows that said Carlton was a Revolutionary pensioner. This deponent further says that he was present at the time & place when said John Carlton married said Ann Moore, said Mar- -riage was solemnized at Windsor Maine on the twentieth day of June A D 1831 by Rev. Mr Trask, a minister of the gospel, that this deponent was present at the said marriage, he also

knows that said John Carlton died at Palermo Maine - in June A D 1839, He also knows that said Carlton & said Ann lived together as husband & wife until the time of his death as afore- said - That said Ann Carlton after- wards married Mr Ebenezer Moore of Ft Albany & that he died a year or so after said that said Ann Moore has remained a widow since said Ebenezer Moores death & is still a widow - Jonas his Procter mark before me H. C. Pierce
Subscribed and sworn to the day & year first above written by Jonas Procter. To me well known to be the person described in the foregoing to be the person of Windsor a credible & disinterested witness, & that I have no interest in this case & am not concerned in its prosecution.
Before me H. C. Pierce
3/28/47 The Pierce

State of Maine.
PENOBSCOT, ss.
I, NATHAN WESTON, Jr., CLERK OF ALL THE JUDICIAL COURTS in said County, certify that Joseph Bowman and Henry C. Pierce Esquires are and were at the date of their Certificates acting Justices of the Peace in and for our County of Kennebec, and that Chas. P. Brown
Esquire, is, and was at the date of his Certificate
an acting Justice of the Peace, in and for said of Penobscot County, as appears by the papers hereto annexed, that they are duly commissioned and qualified to act as such;
and that the signatures to the annexed papers purporting to be theirs are genuine.
In Testimony Whereof, I have hereunto set my Hand, and affixed the Seal of the SUPREME JUDICIAL COURT for said State, this twenty second day of September in the year of our Lord one thousand eight hundred and fifty
Nathan Weston Jr.
Clerk.

Washington D.C. Sept 28 th 1856.
Hon S. P. Waldo. Sir
I present herewith the application of Mrs Ann Moore for Revolutionary Pension under Act of Feb y 3 rd 1853. Please have it examined as soon as practicable and send the Certificate to me
Respectfully &c Jno P Dickinson

SUBMIT IN DUPLICATE.
1-681
PHONE Branch 476
All inquiries regarding this job should refer to Requisition No.
41949
Requisition for Duplicating, Addressograph, Photostat, and Blue Print Work.
DEPARTMENT OF THE INTERIOR WASHINGTON
CHIEF, Division of Publications, Room G 139.
Please furnish work specified below.
April 9, 1930.
Bureau ordering Pension
Deliver to Room No. 5033
(ALL COPY FOR DUPLICATING WORK SHOULD BE PLAIN AND WRITTEN IN ELITE TYPE, EXACTLY LINE FOR LINE AS IT IS TO APPEAR ON FINISHED JOB.)
Title and description of job photostatic copies of 3 pages from Revolutionary War pension claim of John Carlton, Massachusetts Troops, W.8278.
No. of copies 1 of each Shall form be kept standing? ..... days
For further information see Mrs. M. M. H. Finch Room No. 5033 Phone No. 541
Approved:
Margaret M. H. Finch
Chief Clerk of Bureau.
Chief of Division.
NOTE: No order made "SPECIAL" unless statement showing necessity is written below and approved by Chief Clerk of Bureau ordering
CHECK WORK DESIRED
Duplicate
Multigraph
Mimeograph
Folding
Assembling
Stapling
Electric typewriter
single or double space? .....
Facsimile signature? .....
one side or both sides? .....
Facsimile signature? .....
once or twice?
Once? .....
Twice? .....
Side? .....
End? .....
Fill in addresses? .....
Dated? .....
Addressograph from lists .....
Envelopes, size .....
Proof list .....
Labels (submit sample) .....
Fill in letters .....
Cards, size .....
Pay rolls .....
Corrections .....
Tabulation sheets .....
Photostat X Size actual
Official use? .....
Repay? .....
Yes $ .45
Blue Print Size .....
Official use? .....
Repay? .....
$
Remarks .....
See request in Joel Adams, W.23409.

NOTE: Routine changes of addresses may be made on this blank without formal reference through or initialing of chiefs of branches or chief clerks of bureaus.
.....192
(Date)
INDICATE BY AN X IN PROPER SQUARE ACTION TO BE TAKEN.
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} On list.....
as follows:
Now reads   1 .....  2 .....  3 .....  4 .....  5 ..... 
Should read   1 .....  2 .....  3 .....  4 .....  5 ..... 
FOR USE OF DUPLICATING AND ADDRESSING SECTION
ADDRESSOGRAPH
The above change was made ..... 192
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