This is believed to have been designed by Jacob Perkins who is best known for creating the Washington funeral medals - Baker 165-169. The portrait in the center of this die trial appears to be the same as that used on the above listed funeral medals.
Judd lists two known, one of which is a shell. The shell is ex Stickney lot 400, Granberg-1914 ANS exhibit, 47 ANA from which this illustration was taken. The struck example is apparently ex Col Green (see B.G. Johnson invoice to Mehl dated 5/11/42), Boyd, Ford-Stacks 5/04, Southern collection, Stacks-Bowers 2011 ANA - NGCAU55. It is illustrated below.
Photo courtesy of Stacks.
Perkins is also credited with the creation of an 1818 cent JC1818-1/P5065 and a dollar die trial dated 1819 JC1819-1/P5070.