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p. <br />V <br />�i <br />In compliance with State Assistance Statutes in Section 68 Comp. St. Supp. 1937, 1 hereby declare the following described <br />real estate as all of the real estate owned in whole or in part by myself and/or my spouse. <br />1. Legal description of real estate used by me as place of my residence: <br />2. Legal description of all real estate not used by me as place of my residence: <br />Witness <br />Signed <br />VERIFICATION <br />Applicant for Assistance <br />have investigated the ---------------------- ............ .-------------------- ................ _............... ...... County records and hereby certify the above description(s) <br />to be correct to the best of my knowledge. <br />County Assistance Director or Visitor <br />To: State Assistance Director, ............... .....------- ------------- ----------------------------- ------ - ---- County <br />1008 State Capitol, <br />_............................. 19-- <br />Lincoln, Nebraska <br />Received for record Certificate of Award for Application No ....... _....................................... _........ (Old Age Assistance), (Blind Assist- <br />ance) at--. ------- _._..--------_----......o'clock and ----- _ ....................minutes .---------- M. in compliance with Sec. 68-258 Comp. St. Supp., 1937 as amended <br />by L. B. 389, 53rd Session Nebraska Legislature, or 68-413 Com. St. Supp., 1939. <br />111Y WCYYtIR p. M11O I,WY. IpY. <br />Sig <br />Register of Deeds <br />