The Cummnnuealth nf Massarhusetia
e used in cases of Cieil and Spanish War soldiers or their dependents.
This blank: NOT to
Military Aid
Certificate of Reasons for Disbursing State or
UNDER CHAPTER 179, GENERAL ACTS OF 1917.
t
TO BE FILLED IN CAREFULLY FOR EVERY APPLICANT.
Date,
19
Name of applicant.
Residence
Age at date.
1
State nature of applicant's disability
2.
If addicted to idleness, intemperate or vicious
habits, and
3.
necessities arise from same.
What amount per month does the soldier on whose service this claim is based allot or otherwise
4
contribute for the support of his dependents of any pay authorized by the State or by the
U. S. Government?
of the soldier allow
ny amount to the soldier or for the support of his
Does
employ
dependents?
What were the weekly earnings of the soldier at time
of enlistment or muster in to the Federal Service?
State total amount contributed weekly at that time to the applicant by the soldier
If so, how much per week?.
How much of this amount was in payment of soldier's board or other indebtedness ?.
What are the present resources of the applicant? From labor, business, etc.
5
Am't of Mort.
6.
Description, value and location of
property:
Assessed value of real estate,
Amount of money in bank, 8
Amount of personal property,
Value of other resources, 8
If applicant pays rent, state amount paid:
7.
If applicant boarde, state amount paid:
8.
How many and who are thee dependents? .
9
In the case of the mother, state whether she is a widowed
mother or has
husband living. (If living, give amount
of his weekly earnings or income.)
Has the applicant
applicant heretoforo drawn State or Mili
tary Aid? If so, where and when?
or any connection of the
10.
Do the Municipal Authorities recommend Assistance S
If so, state the amount,
Remarks:
OVER
