That your petitioner acquired her claim to the aforesaid service or labor of said Ellen Nora and Caroline in manner following:Here state how the claim was acquired, when, from whom, and for what price or consideration; and, if held under any written evidence of title, make exhibit thereof, or refer to the public record where the same may be found. the Said Ellen Nora was a Gift from her mother Susannah Anstead of Washington City, D.C. and Said Caroline is her offspring, born in Washington City DC.

That your petitioner's claim to the service or labor of said Ellen Nora & Caroline was, at the time of said discharge therefrom, of the value of Twelve hundred dollars in money.Here state such facts, if any there be, touching the value of the petitioner's claim to the service or labor of the person, as may enhance the same, and also such facts, if any, touching the moral, mental, and bodily infirmities or defects of said person, as impair the value of the petitioner's claim to such service or labor, and conclude such statement with an averment that the petitioner knows of no other infirmities or defects of said person which impair the value of petitioner's claim to such service or labor, and that he believes none other to exist. If the petitioner specify no such infirmity or defect, then his statement touching the value of his claim should conclude with an averment that he has no knowledge of any such infirmity or defect. the mother Ellen Nora, being as aforesaid young, healthy, Good Cook Washer and Ironer and Good Worker Generally and to the Best of my Knowledge and Belief Neither of said Negroes have any moral defect

Your petitioner hereby declares that she bears true and faithful allegiance to the Government of the United States, and that she has not borne arms against the United States in the present rebellion, nor in any way given aid or comfort thereto.

And your petitioner further states and alleges, that she has not brought said Negroes into the District of Columbia since the passage of said act of Congress; and that, at the time of the passage thereof, said Negroes was held to service or labor therein under and by virtue of your petitioner's claim to such service or labor.

Your petitioner further states and alleges, that she said claim to the service or labor of said Negroes does not originate in or by virtue of any transfer heretofore made by any person who has in any manner aided or sustained the present rebellion against the Government of the United States.

And your petitioner prays the said Commissioners to investigate and determine the validity of her said claim to the service or labor of said Negroes herein above set forth; and if the same be found to be valid, that they appraise and apportion the value of said claim in money, and report the same to the Secretary of the Treasury of the United States, in conformity to the provisions of said act of Congress.