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� [below all handwritten] State of Maine

Penobscot ss. At a Circuit Court of Common Pleas for the third Eastern Circuit, begun and holden at Bangor in and for said County on the third Monday of September A.D. 1821.

On the second day of said Court, personally appeared in open Court, being a Court of Record, and common law jurisdiction, Amos Dole aged sixty four years this present month[clause inserted] resident in Orrington in said County of Penobscot, who being first sworn according to law, doth on his oath declare, that he served in the Revolutionary War, agreeable to his statement of the twenty seventh of June A.D. 1820. A certified copy of which duly forwarded to the War Department, and which is more fully put forth in his original application made on the first day of April A.D. 1818 upon which he received his Pension Certificate No. 9.164.

And I Amos Dole do 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.

Amos Dole[signature]