The Cnmmnnmealth nf Mansarhuetta
Military Aid
Certificate of Reasons for Disbursing State or
UNDER CHAPTER 314, GENERAL ACTS OF 1916.
t
TO BE FILLED IN CAREFULLY FOR EVERY APPLICANT.
Date,
19
Name of applicant.
Residence
Age at date.
State nature of applicant's disability
2
If addicted to idleness, intemperate or vicious
habits, and if necessities arise from same.
3
What amount per month does the soldier on whose service this claim is based allot or otherwise
contribute for the support of his dependents of any pay authorized by the State or Act of
4
Congress approved August 29, 191
Does the employer of the soldier allow any amount to the soldier or for the support of his
If so, how much per week?.
dependents?
What are the present resources of the From labor, business, etc.
applicant? Monthly pension.
Am't of Mort.
Description, value and location of
property:
Assessed value of real estate, 8
6.
Amount of money in bank, 8
Amount of personal property, 8
Value of other resources, 8
If applicant pays rent, state amount paid:
7.
If applicant boarde, state amount paid:
8.
9. How many and who are the dependents?
In the case of the mother, state whether she
is a widowed mother or has a husband
living
Has the applicant or any connection of the)
applicant heretofore drawn State or Mili-
tary Aid? If so, where and when?
10
Do the Municipal Authorities recommend Assistance3
If so, state the amount,
Remarks:
D OVER
