Claim of Soldier for Increase of Pension

(Form Published by Robert Clarke & Co, Law Publishers, 55 West Fourth St. Cincinnati)

The supplementary pension act approved June 6, 1866, provides increased rates of pension over those granted by the act of July 14, 1862, in the following case, via -

1st grade - $25 per month to all those invalids entitled, under the act of July 14, 1862, to a lower rate of pension, on account of service rendered since March 4, 1861, "Who shall have lost the sight of both eyes, or who shall have lost both hands, or been permanently and totally disabled in the same, or otherwise so permanently and totally disabled as to render then utterly helpless, or so nearly as to require the constant personal aid and attendance of another person"-

2nd grade - $20 per month to those invalids who, being entitled under like conditions to a lower rate of pension, "shall have lost both feet, or one hand and one foot, or been totally and permanently disabled in the same or otherwise so disabled as to incapacitated for performing any manual labor, but not so much so as to require constant personal aid and attention"-

3rd grade - $15 per month to those invalids who, under like conditions, "shall have lost one hand and one foot, or been totally and permanently disabled in the same, or otherwise so disabled as to render their inability to perform manual labor equivalent to the loss of a hand or foot."

This declaration is to be signed and acknowledged by the applicant and two witnesses before a clerk of the court. No surgical examination and additional evidence is required, except specially ordered by the department. The application, with original certificate, to be forwarded to commissioner of pensions.

The State of Ohio, County of Montgomery,

On this 5" day of April, A.D. 1871, personally appeared before me (1) Clk of the com Pleas court in & for said county and state, William Little aged 26" years, a resident of Nat. Mil Asylum, in the county of Montgomery, and the state of Ohio. who, being duly sworn according to law declares that he is a pensioner of the United States duly enrolled at the Cleveland O. pension agency at the rate of Eight dollars per month by reason of disability incurred in the Military service of the United States (3) Co "B" 12. Ohio Vol Cavy.

and that his present physical condition is such that he believes himself entitled to receive and increased pension of the (4) Third grade provided for in the first section of the supplementary pension act, approved June 6, 1866. He further declares that he is disabled in the following manner to wit: (5) Gun shot wound of right elbow joint rendering the joint stiff & the arm useless. So that he cannot perform manual labor. he cannot even write with his right hand.

and hereby appoints Daniel O'Driscoll his true and lawful attorney, and authorized him to present and procure this claim, and to receive and receipt for any orders or certificates that may be issued in satisfaction thereof.

William Little (signature)
Nat. Mil Asylum
Dayton, Ohio