| 16. | Statement of resources: | ||||||||||
| Insurance uncollected, $ | In what companies? | ||||||||||
| Savings, $ | Which bank, or where? | ||||||||||
| Real estate, $ | Location | ||||||||||
| Stock, etc., on hand at present | Where? | ||||||||||
Above form as [illustration]
| [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? | ||||||
Above form as [illustration]
| [FORM B—BUSINESS] | Ap. No. |
| 1. | Nature of business to be re-established | ||||||||||||
| 2. | Location April 18, 1906: | Proposed location: | |||||||||||
| 3. | Number and size of rooms for | ||||||||||||
| a. | Store | a. | |||||||||||
| b. | Shop | b. | |||||||||||
| c. | Other use | c. | |||||||||||
| 4. | 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 | $ | $ |
| (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 | ||
| $ | $ | ||
| 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 | $ | |
Above form as [illustration]
| [FORM C—LODGING HOUSE] | Ap. No. |