I, __________________________ a native of the State of ________________________ and now a citizen of Tennessee, resident at ___________________ in the County of __________________________ in the said State of Tennessee, and who was a soldier from the State of ___________  in the war between the United States and the Confederate States, do hereby apply for aid under the Act of General Assembly of Tennessee, entitled "An Act for the benefit of the indigent and disabled soldiers of the late war between the States, and to fix the fees of attorneys or agents for procuring such pension, and fixing a penalty for the violation of the same." And I do solemnly swear that , while in the discharge of my duty in the service of the Confederate or United States, as a member of _________________________
I was wounded in the battle of or battles of ___________________________________________________
and that from the effects of such wound or wounds I was disabled as follows: ____________________________________

and that by reason of such wound and disability, I am now entitled to receive the benefits of this Act. I further swear that I do not hold any national, State or county office, nor do I receive aid or a pension from any other State, or from the United States, and that I am not an inmate of any soldier's home, and that I am unable to earn a reasonable support for myself and family. I do further solemnly swear that the answers given to the following questions are true:
 

In what county, State and year were you born?
Ans:

When did you enlist, and in what command? Give the names of regimental and company officers under whom you were serving at date of wound or wounds.
Ans:

In what battle or battles were you wounded, and if not in battle state under what circumstances you received the injury or injuries?
Ans:

What was the precise nature of your wound or wounds?
Ans:

What limb, if any, did you lose by reason of said wound or wounds, and if no limb, state fully the disability caused by said wound or wounds, and is said disability permanent?
Ans:

Were you incapacitated for service by reason of said wound, wounds or service?
Ans:

Were you discharged from the army by reason of said wound, wounds or service?
Ans:

If discharged from the army, where were you and what did you do until the close of the war?
Ans:

What was the name of the surgeon that attended you?
Ans:

Are you married, or have you been married?
Ans:

Is so, what is the size of your family?
Ans:

What are the respective ages of your wife and children?
Ans:

To what sex do your children belong?
Ans:

In what business are you now engaged, if any; and what do you earn?
Ans:

What estate have you in your own right, real and personal, and what is its value?
Ans:

What estate has your wife in her own right, real and personal, and what is its value?
Ans:

How have you derived support for yourself and family for the last five years?
Ans:

Do you use intoxicants to any extent?
Ans:

How long have you been an actual resident of the State of Tennessee?
Ans:

Have you an attorney to look after this application?
Ans:

If so, give his name and address?
Ans:
 

Witness my hand, this _______ day of  _______ 189____

______________________________

WITNESSES:

______________________________ Physician

______________________________ Witness

______________________________ Witness
 

State of Tennessee,
__________ County }  Personally appeared before me ______________________________  Clerk of the County Court of said county, and the above named  _______________________ the applicant, with whom I am personally acquainted, and having the application read and fully explained to him, as well as the statements and answers therein made, made oath that the said statement and answers are true.
 

Witness my hand at office this _________ day of __________ 189____
 

_______________________  Clerk

State of Tennessee,
_________ County } Personally appeared before me ______________________________ Clerk of the County Court of said county, the above named ______________________ one of the subscribing witnesses to the foregoing application, and who is a physician of good standing, and being duly sworn, says that he has carefully and thoroughly examined _____________________ the applicant, and finds him laboring under the following disabilities:
 

Witness my hand at office this __________ day of ___________ 189___
 

_______________________  Clerk

State of Tennessee,
_________ County, } Personally appeared before me ______________________________ Clerk of the County Court of said county, the above named _______________________ and _________________________ two of the subscribing witnesses to the foregoing application, with whom I am personally acquainted, and known to me to be citizens of veracity and standing in this community, and who make oath that they are personally acquainted with the foregoing applicant, and that the facts set forth and statements made in his application are correct and true, to the best of their knowledge and belief, and that they have no interest in this claim, and that said applicant's habits are good and free from dishonor. And _____________________ further make oath to the following facts touching the applicant's service in the _______________________ army.

________________________________________________________________________________________
________________________________________________________________________________________
 

Witness my hand, at office, this ________ day of ___________ 189_________
 

______________________ Clerk

(This completes the information contained within the application. The remainder of the pension file contains correspondence between the applicant and pension board, correspondence from fellow soldiers corroborating military service, correspondence from other state military offices confirming or denying soldier's enlistment in the state's militia, etc.)

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