b. of a. o. 
Form A. 125M- -0 29-21 
AFFIDAVIT IN CLAIM FOR BOUNTY 
State of Pennsylvania 
-ss: 
County of 
Before me, the undersigned, a..™--—. 
in and for said County, personally appeared 
whose postoffice address is— 
(Official title) 
(Name of Claimant.) 
(Correct Po»t Office Address i® important) 
(B. D. or Street No.) 
who being duly sworn according to law doth depose and say that upon the..... 
.day of. 
in the County oi 
also upon the.... 
in the County of— 
also upon the___ 
day of. 
■ »n« 
_, 19_, he did kill.. 
...___.Township oL~ 
—, 19.-, he did kilL 
.Township of. 
(Number) 
(Name of animal) 
wixwiow* 
Penn^.; 
(Number) 
(Name of animal) 
i 
_, Pcnna.; 
day of. 
in the County of—™ 
also upon the—__ day of. 
in the County of_.....__...... 
also upon the____day of __ 
in the County of.____ 
also upon the...™....._ day of... _ 
in the County of™___ 
also upon the.._ 
19., he did kill. 
....Township of 
(Number) 
(Name of animal) 
f 
__._, Pcnna.; 
19™.he did kill™ 
(Number) 
——Township of. 
(Name of animal) 
r 
_Penna.; 
™, 19.—...... he did kill— 
(Number) 
.....Township of. 
19™., he did kill™ 
(Number) 
day of_ 
-Township of.. 
, 19._, he did kill. 
(Name of animal) 
„_—, Penna.; 
(Name of animal) 
-, Penna.; 
(Number) 
(Name of animal) 
in the County of™ 
also upon the— 
in the County of™ 
also upon the_ 
in the County 
also upon the.. 
in the County of. 
day of.... 
™—.—Township oL 
19™—, he did kill. 
.Township of. 
Penna*; 
(Number) 
(Name of animal) 
-, Penna.; 
day of. 
, 19-, he did kill. 
(Number) 
(Name of animal) 
day of. 
-Township of 
19._.., he did kilL 
-Township of. 
«Mfcr> \U* 
Penna.; 
(Number) 
jug MRC'illHHMM* 
(Name of animal) 
--Penna., 
and being desirous of securing the bounty for such killing as provided by the Act of May 23d, 
1919, as amended by Act of April 1st, 1921, herewith presents the skin_ of such animal_ 
for examination. He further swears that the animal- for which the skin_as presented was 
were 
taken 
was 
is 
the skin-of the aniami. 
were billed within the Commonwealth of Pennsylvania, and 
as specifically named in this affidavit; that such animal- were not raised in captivity and 
not purchased or received from the party actually killing same, and not brought into this State 
from another State or country, and that his claim as made is legitimate in all respects. 
Sworn to and subscribed before me this__ ") 
J 
(B« mure that Claimant signs here) 
NOTE:—Vn skin sent to Harrisburg vHIl ho r**tnrv>M ev*H*pt hr request.. Wo there¬ 
fore wok that v**n fn«lI «*m 
«*ur It* thi. by tho sentence t*el«*w. |f y«*u want 
8k In returned rr«w out the 
word “NOT** In the line below. 
WE DO NOT WANT SKIN RETURNED. 
NOTTS TO OFFICIALS. Read other aide carefully and save ponalhle trouble. 
Officials will please complete records on the back of thi* affidavit as fax as they are 
concerned- 
READ AND OBSERVE 
Always send the affidavit and akin* 
together. Don’t forward separately. Be 
sure and place your name aud address on 
every park age. This will avoid losses. 
Skin and dry all pelts same as when ship¬ 
ping to fur dealers. 
We will forward valuable pelts direct to 
fur dealers If you enclose tag or legible 
shipping instructions. 
GAME COMMISSION. 
