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I do solemnly swear before Almighty God, the searcher of all hearts, that I am in destitute circumstances : that I have nothing to subsist upon : that I have no money to purchase subsistence, and that I have made every effort in my power to obtain honest employment, and without success : that I am a [blank] with [blank] helpless children, and that unless relief is afforded me [sic] must perish. I further declare that I have taken the Oath of Allegiance to the United States government.

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