This preprinted and handwritten form records the successful claim against the Confederate state of South Carolina for the death of an impressed enslaved man named Dick from dysentery on October, 26, 1862. Samuel Jordan, who enslaved Dick, was rewarded $750.00 by the government. The document is signed by James Tupper, the state auditor. The reverse of the paper reads "State of South Carolina / No. 342 / In the matter of the / claim of / Samuel Jordan / Report of the / State Auditor."