G Chin4.2
American Agencies for War Relief
Civilian Relief
Investigation and Record Blanks
The Commonmealth of Massarhusetts
The Caumommealth nf Massachusetts
Certificate of Reasons for Disbursing State or Military Aid
UNDER CHAPTR OESEBAL ACTS OF 1 .
casa Y ron EYERY APTSICANT
To BE FILLED
We,the undenigned, officials chargel with the disbarsemeat of Military and Stale Aid is the
Date
City-Town ef
certify that we believe, and have good reason to believe, that the statesenta within made ace true.
Sane of applicast
Reeidences
1. Age at date.
. Sate tatare ot sppliowas's disality
s.
pale or ricloas s
d it
What amoant rer month does the sobdior en whose service thle elalm is basel allat or otherwiee
4
C t ta of say pay aatberised by the Sale or Aet ed
Dos the emploger
the soldiee allow a
anoant to
soidier
r foe the sapport of his
how mseh per voek?
dependestah
Ir
Mah e Frem labor, besiarm, ese
signatare of spplieant,
Description, valse and location od ( Assesod value of real estate,
property
Am't of Mect.
6
Amount of money in bank, e
Value of ether resoarces, 8
19
, If apolleant pars rent, state amount pail:
Thes personally appearel the abore-namod odieials and applionnt, vis
& Itapelicant boands, state amoant paid:.
9 How masy and wha are the depondents?
Is the ease ef the olher, s
and male on
that the abova slalement, by them signel, is trae
living.
Before me,
10. H
the applicss or say con
tary Aidt If so, where and w hen?k
l
temarksr
OVER
