APPLICATION FORMS FOR BUSINESS REHABILITATION

	[FORM A—GENERAL STATEMENT. FACE]	Ap. No.
APPLICATION FOR BUSINESS REHABILITATION


1.	Full name	Age
2.	Present residence
3.	Residence prior to April 18, 1906
4.	Present occupation and place of employment
5.	Physical condition
6.	Nature of business to be re-established
7.	How long in this business?
8.	Location of business on April 18, 1906
9.	How long at above address?
10.	Prior address
11.	Has location for re-establishment of the business been secured?
12.	If so, where, and under what conditions?
13.	If no location has been secured, what is the outlook for a definite and permanent
	location?


14.	Statement of losses:		Amount.Where?			Amount.Where?
	a.	Store		f.	Houses
	b.	Office		g.	Furniture
	c.	Fixtures		h.	Clothing
	d.	Stock		i.	Misc. (household)
	e.	Misc. (business)
15.	On which of above has insurance been collected, and how much?


[FORM A—GENERAL STATEMENT. REVERSE]
17.	How much owing on real estate, and to whom?

18.	Is indebtedness covered by mortgage?
19.	When is mortgage due, and has interest been paid to date?
20.	Has applicant any other income, from any source whatever, such as pensions, stock
dividends, annuities, interests, etc.?
21.	Statement of assets at time of fire (including debits upon applicant’s books, and stating
how much of the amount is now collectible)

22.	Statement of liabilities (including all unpaid invoices at time of fire)

23.	Names and present addresses of firms from whom goods were purchased

24.	Names of others, firms or individuals, well acquainted with applicant in a business way.
(Secure from two or more of these firms letters addressed to the Rehabilitation Committee,
certifying to applicant’s business standing. Send these in with your application)


25.	Personal references, names and present addresses. (Send in letters from two or more of
these)


26.	Others in family:

NAME	Age	Relationship to Applicant	Present Address	Present Occupation	Name and Address Present Employer	Av. Mo. Inc.






27. Were any members besides the applicant interested in the business before the fire,
and, if so, in what capacity?

[FORM B—BUSINESS]

Ap. No.

Nature of business to be re-established

Location April 18, 1906:

Proposed location:

Number and size of rooms for

Store

Shop

Other use

Number of employees

		Schedule of prior location	Schedule of proposed location
5.	Fixtures, total value	$	$
	(Submit itemized list of same on separate sheet attached. In listing proposed expenditures,include only those articles absolutely necessary to a start.)
6.	Stock
	a. Cost, wholesale	$	$
	b. Sale price, retail	$	$
	(Submit itemized list on separate sheet attached. In listing proposed stock,include only those articles absolutely necessary to a start.)
7.	Rent, per month	$	$
7.	(or) lease, for year ; per month	$	$
8.	Labor, per month	$	$
9.	Miscellaneous, not included above	$	$
10.	Total monthly expense of business	$	$
11.	Net monthly income of business	$	$
12.	Average monthly income of family aside from business
12.		$	$
13.	Total income, all sources	$	$
14.	Total monthly living expense of family	$	$
15.	Margin of profit	$	$
16.	Can repay to Relief and Red Cross Fund, monthly		$

[FORM C—LODGING HOUSE]

Ap. No.

		Schedule of prior location per month	Schedule of proposed location per month
2.	Number of rooms
2.	Number available for subletting
3.	Rent	$	$
3.	(or) lease for year ; monthly payment	$	$
4.	Water	$	$
5.	Light	$	$
6.	Labor	$	$
7.	Laundry	$	$
8.	Insurance	$	$
9.	Instalments on additional furniture	$	$
10.	Miscellaneous, not included above	$	$
11.	Total monthly expense of house	$	$
12.	Total monthly income of house	$	$
13.	Net monthly income of house	$	$
14.	Average monthly income of family from other sources
14.		$	$
15.	Total income of family from all sources	$	$
16.	Total monthly living expenses of family, aside from expenses of house
16.		$	$
17.	Margin of profit	$	$
18.	Can repay to Relief and Red Cross Fund, monthly		$