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[typed form with handwritten insertions]

�State of Maine. KENNEBEC COUNTY, ss. ON this Fifteenth[handwritten] day of [stricken] August[handwritten], 1820, personally appeared before Josiah Stebbins esq.[handwritten] 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 being the power of fine and imprisonment, Daniel Johnson[handwritten] aged fifty six[handwritten] years, resident in Belfast[handwritten] in the County of Hancock now of Augusta[handwritten] 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 Farewell[handwritten] and Regiment commanded by Colonel Kelly[handwritten] of the line of the State of New Hampshire[handwritten] upon the Continental Establishment, for the period of nearly eleven months[handwritten]

that his original declaration was made before Judge Crosby[handwritten] on the eleventh[handwritten] day or April[handwritten] 1818; that he is now on the Maine Roll and that his pension certificate is numbered 13194[handwritten]. And I, the said Daniel Johnson[handwritten] do further solemnly swear, that I was a resident 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 of debts, due to me; nor have I any income, other than what is contained in the schedule hereto annexed, and by me subscribed.

Daniel Johnson[signature]

The following is a Schedule of my whole Estate and income, necessary clothing and bedding excepted, viz:

[handwritten paragraph follows] About five acres of land with a poor house thereon of the value of fifty dollars - one yoke of oxen of the value of thirty five dollars - one cow of the value of twelve dollars - 5 sheep of the value of five dollars - one horse of the value of twenty dollars - 1 yearling heifer of the value of four dollars - two swine of the value of four dollars - Household furniture very poor + old worth five dollars - a few old farming [illegible] worth five dollars - I have no debts due to me that can be collected, and I owe as much as two hundred dollars - the income of the above property does not exceed twenty dollars a year - My occupation has been that of a cordswain but from age and infirmity, having nearly lost my eyesight, am unable to work at that, or perform any other labor - My family consists of myself, my wife Jane aged fifty nine years, very feeble and unable to work and my Daughter