This is believed to have been designed by Jacob Perkins who is best known for creating the Washington funeral medals Baker 165-169.
It is unique and is in the American Numismatic Society ex F.C.C. Boyd in 1948. Per Pollock, it was acquired in 1934 from a descendent of the Perkins family.
Perkins is also credited with the creation of an 1818 cent JC1818-1/P5065 and a dollar die trial dated 1818 JC1818-2/P5067.
Photo courtesy of the American Numismatic Society, accession number 1948.108.2.