Form no 158. 25,000-12-7-09
Sworn Statement of _______________________________ ____________________________________________ in support of his application for Homestead Patent for ____________________ of __________Sec. __________Thp. __________Rge. __________of __________Meridian.
1.	What is your name in full, age, occupation, and Post Office address?	______________________________ ______________________________
2.	(1.) Are you a British subject at the present time? and (2) have you always been one? (3) are you a British Subject by Birth, Naturalization or Repatriation? (Note) If by naturalization or repatriation, certificate must be furnished. If through parents, certified copy of certificate required, or description of land homesteaded by Father or Mother.	(1) ______________________________ (2) ______________________________ (3) ______________________________
3.	(a) When did you obtain homestead entry, (b) when did you build your house thereon, and (c) when did you commence actual residence thereon?	(a)______________________________ (b)______________________________ (c)______________________________
4.	What portion of each year since commencement of residence have you lived upon the land, giving actual dates?	______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________
5.	When absent from your homestead where have you resided and what has been your occupation?	______________________________ ______________________________ ______________________________
6.	Of whom do you family consist; when did they first commence residence upon this homestead, and for what portion of the year since that date have they resided upon it?	______________________________ ______________________________ ______________________________
7.	If residence has been performed on land owned by yourself of duly authorized relative, describe such land:--	Section __________Thp__________Rge.__________Mer.
	(a) When (1) and how (2) was such land acquired?	(a)(1)___________(2)___________
	(b)By whom (1) was the land acquired, and who (2) is the present owner thereof?	(b)(1)___________(2)___________
	(c)What buildings are on such land, and what is the present value thereof?	(c)___________________________ ______________________________ ______________________________ ______________________________
	(d) State each month or part of month you have resided on your land.	______________________________ ______________________________ ______________________________
	State each month or part of month you and your (Father, mother, son, daughter, sister, brother) have resided on the latter's land.	______________________________ ______________________________ ______________________________
8.	How much breaking have you done upon your homestead in each year since you obtained entry, and how many acres have you cultivated each year?	Year 1._ _ _ Broke _____acres, cropped _____acres Year 1._ _ _ Broke _____acres, cropped _____acres Year 1._ _ _ Broke _____acres, cropped _____acres Year 1._ _ _ Broke _____acres, cropped _____acres Year 1._ _ _ Broke _____acres, cropped _____acres Year 1._ _ _ Broke _____acres, cropped _____acres
9.	What stock of which you are the owner have you had on your homestead each year since date of perfecting entry?	______________________________ ______________________________ ______________________________ ______________________________

10.	What is the size of your house on your homestead, of what material, and what is its present cash value?	______________________________ ______________________________
11.	What other buildings have you erected on your homestead? What other improvements have you made thereon, and what is the cash value of the same?	______________________________ ______________________________ ______________________________
12.	What extent of fencing have you made on your homestead, and what is the present cash value thereof?	______________________________ ______________________________ ______________________________ ______________________________
13.	Are there any indications of minerals or quarries on your homestead? If so, state nature of same, and whether the land is more valuable for agricultural than any other purpose.	______________________________ ______________________________
14.	Have you had any other homestead entry? If so, describe it and say what became of it.	______________________________ ______________________________
15.	Have you mortgaged, assigned or transferred or agreed to mortgage, assign, or transfer you present homestead or any part thereof? If so, when and to whom?	______________________________ ______________________________
______________________________ ______________________________ To Wit: I, ______________________________ do solemnly swear that the answers to the foregoing questions are true and correct in every particular. That I claim a Patent for this Homestead under the provisions of the "Dominion Lands Act." That I obtained an entry, and claim a Patent for the same for my own benefit, and not in the interest or for the benefit of any other person or persons whomever.
SO HELP ME GOD.
Sworn before me at ______________________________
_____________________________ A.D. 19 _ _ _____________________________
Having first been read over and explained to the said applicant.
______________________________ Agent of the Dominion Lands, or Homestead Inspector for the _________________ District.
I recommend the foregoing application for Patent, believing that the homestead requirements of the "Dominion Lands Act" have, in this case been complied with. Dated at ________________________________ ______________________________ ______________________________A.D. 19 _ _ Local Agent of Dominion Lands for ______________District.
Ottawa, ______________________________19 _ _ Accepted as sufficient,______________________________ Acting Deputy, Commissioner.
I hereby certify that ______________________________ has to-day produced evidence showing ownership of the ______________________________ of Section ______________________________ Thp. ______________________________ Rge. ______________________________ Mer., from the ______________________________ day of ______________________________ to the present time.
______________________________
Date ______________________________ 19 _ _ The Officer taking this application for patent is requested to exercise particular care that the name of the homesteader is given in full and correctly spelt.

Homestead Forms Index

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Previously published by J.Adamson, http://rootsweb.com/~skwheat/homestead/homestead-forms.html ,
Originally published: Oct 26 99 22:31:51 PST