Sworn Statement of ______________
___________________________________
of Sec. _______, Thp. _______ , Rge. _______ of _______ Meridian.
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| 1. | What is your occupation, and how long have you known the applicant?
| _______________________
_______________________
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| 2. | Where have you resided, since you have known the applicant, give places and dates?
| _______________________
_______________________
_______________________
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| 3. | (1) When did he build his house? and (2) when did he commence actual residence therein, making it his permanent home?
| (1)___________(2) ____________
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| 4. | (a) What portion of each year since commencement of residence has he lived upon the land? Give actual dates. | _______________________
_______________________
_______________________
_______________________
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| | (b) If his residence has been on land owned by himself, or duly authorized relative, describe such land, and give actual dates of residence together with father, mother, son, daughter, brother, or sister, as the case may be.
| _______________________
_______________________
_______________________
_______________________
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| 5. | Has homesteader's family resided with him? Give actual dates. | _______________________
_______________________
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| 6. | How much breaking, and what area has been cropped in each year upon his homestead?
| 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.
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| 7. | What stock of which applicant is owner has he had on his homestead or purchased land each year since date of perfecting entry? | _______________________
_______________________
_______________________
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| 8. | What is the size of his house on his present homestead, and what material, and what is it the present case value thereof? | _______________________
_______________________
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| 9. | What extent of fencing has he made on his homestead, and what material, and what is the present cash value? | _______________________
_______________________
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| 10. | What other buildings have been erected on his homestead? What other improvements have been made thereon, and what is the cash value of the same?
| _______________________
_______________________
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| 11. | Have you any interest, direct or indirect, in this application? | _______________________
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| 12. | Do you believe the claimant has acted in good faith in obtaining his entry, and in making his application for patent? | _______________________
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_______________________
_______________________
I, _______________________ of _______________________,
make oath and say that the answers to the foregoing questions are true and correct in every particular.
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SO HELP ME GOD.
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Sworn before me at _______________________
this _________ day of __________ 19 _ _ _______________________
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Having been first read over and explained to the Witness.
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_______________________
Local Agent of Dominion Lands or Homestead Inspector
for the _______________________ District.
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