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� [the following is a pre-printed form with handwritten insertions, deletions and exhibits] STATE OF MAINE

KENNEBEC COUNTY, ss.

On the Eighteenth [handwritten] day of September [handwritten] --- , 1820 personally appeared before Nathan Weston Junior [handwritten] a [handwritten] Justice of the Circuit[stricken] Supreme Judicial [handwritten inserted] Court of Common Pleas for the Counties of Lincoln, Kennebec and Somserset, [stricken] being a Court of Record for said Counties [stricken] State [handwritten inserted] proceeding according to the course of the common law, having original jurisdiction, unlimited in amount, being a record of their proceedings, and having the power of fine and imprisonment, John Burrell [handwritten] aged sixty eight [handwritten] years, resident in Plan No. 3[handwritten] [Plantation No 3] in the County of Penobscot [handwritten] within said Circuit [stricken] State [handwritten insertion] 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 Fuller [handwritten] and Regiment commanded by Colonel Bond [handwritten] of the line of the State of Massachusetts [handwritten] upon the Continental Establishment, for the period of one year [handwritten]

that his original declaration was made before Judge Weston [handwritten] on the twenty sixth [handwritten] day of June [handwritten] 1819; that he is now on the Maine Roll, and that his pension certificate is numbered 13133. And I, the said John Burrell [handwritten] that I was a resident citizen of the United States on the 18th day of March 1818; and that I have not since that time by gift, sale, or in any manner 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 18th day of March, 1818; 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; that my occupation and ability to pursue the same, together with the number and other particulars of my family, are in fact and in truth as is particularly described on the back hereof, also subscribed by me.

John Burrell [signature]

The following is a Schedule of my whole Estate and income, necessary clothing and bedding excepted, viz: [handwritten] Real Estate None [all underlined] One Cow of the value of twelve dollars one Old horse (13 years old) - twenty dollars 4 Sheep ----- four dollars 1 swine ____ four dollars Old house hold Stuff (besides bedding) Eight dollars I have no debts due me that can be collected, and have [?] [?] me upon debts I owe, which I am wholly un able to pay -- my family consists of four persons myself - my wife Eleanor aged thirty six years subject to fits, my son Jacob aged two years, and Mary Ann age seven months. I have no trade, my occupation is that of a farmer but for age + infirmity I am un [inserted] able to labor more than one half of the time -- Except the above and my clothing and bedding I have no estate or income whatever John Burrell [signature]