Part 6 — APPENDIX II FORMS AND CIRCULARS

Appendix II FORMS AND CIRCULARS

PAGE

First registration card (Face) 425

First registration card (Reverse) 426

Food card (Face and Reverse) 427

Second registration card (Face) 428

Second registration card (Reverse) 429

Tent record sheet 430

Camp commander’s report sheet 431

Rehabilitation Committee

Report form 432

Paster 433

Circular 434

Application Blank 435

Circular letter of inquiry 436

Bureau of Special Relief

Recommendation form 437

Report form 438

Medical service form 439

Order form A 440

Order form B 441

Bureau of Hospitals

Hospital report sheet 442

Application forms for business rehabilitation 443

Application for bonus 447

Land and Building Department. Notice 448

Application for housing grant 449

FIRST REGISTRATION CARD (Face)

NATIONAL RED CROSS

General Register of Applicants for Relief, San Francisco, 1906.

Food Station No........

Surname and given names of head of family. Total number of persons for whom rations are asked: Food Card No. Date of this registration.

Men .......... Children ..........

Women .......... Aged, etc. ..........

Present location. Former home or address on April 17th.

Trade or occupation of head of family. Age. Nationality. Union. Former employer.

References, or other memoranda relating to employment:

Membership in: (1) fraternal orders; (2) churches; (3) clubs:

Address of friends to be communicated with:

Present employment: Is it steady? Is applicant owner of real estate? If so, where?

Plans for future:

Relief supplied (other than rations, including transportation):

Remarks:

Above form as illustration

FIRST REGISTRATION CARD (REVERSE)

F o o d C a r d I s s u e d. D a t e.

N o.

Data as to adult bread winners in family or party (not the applicant named on face of card).

Name and sex m.f. m.f. m.f. m.f.

Age and nationality

Trade or occupation

Union

Former employer

References

Present employment

Future plans

Remarks:—

Above form as illustration

FOOD CARD (Face and Reverse)

1 NATIONAL RED CROSS. (See other side.)

2 Food Card.

3 C. No. R. S. No.

4

5

6 This card is issued on

7 (date)

8 It will be good for 10 days ending

9 (date) 31

10 30

11 (Signature of Issuing Officer.) 29

12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Above form as illustration

TAKE NOTICE.

This card must be presented whenever rations are drawn. When drawing rations keep it always in plain sight.

This card is not transferable, and will be honored only when presented by the person to whom it is issued, or by some member of his family or party.

Good only for 10 days.

Renewable after 10 days at the discretion of the registration officer.

Good only at the Relief Station of issue.

If any fraudulent use of this card is attempted it will be taken up and no rations will be issued to the offenders.

SECOND REGISTRATION CARD (Face)

NATIONAL RED CROSS SAN FRANCISCO

NO. SECOND REGISTRATION (DATE)1906

Surname Address No. of Rooms Rent

At present. (Give exactly)

April 17 How long at this address?

First name Age Trade or usual occupation Earnings per wk. ordinarily Physical condition Birth place and race Years in S. F.

Man

Woman

Children LOSSES Description Estimated value

House (owned)

Business: plant? position?

Furniture and clothing

Injury to health

Others in household Insurance: amount? RESOURCES

In what companies?

Savings: amount?Which bank?

Real estate: value?

Location?

Anything else?

Above form as illustration

SECOND REGISTRATION CARD (Reverse)

From which relief station has family received help?

What are bread-winners doing? PLANS FOR FUTURE

Name of employers Family’s estimate on what it needs and its plans:

Present addresses

Is work permanent?

Employers before the fire of Present address

How long does family expect to need help in food? in shelter? in other ways?

Other referencesPresent address Investigator’s suggestion as to what should be done:

Name of Church, Union, or other organization to which any member of family belongs

Relatives: name, address, ability to help

(Signature of investigator)

Action taken:

Above form as illustration

TENT RECORD SHEET

Camp Number.................... TENT RECORD[302] Tent Number....................

OCCUPANTS INVENTORY

No. NAME and Resi- dence Before Fire Age Sex Em- ployed at Earning Relatives Earning Unable to Work Cause Would Work at Will Support Self if Given Could Pay Rent Need Cloth- ing Cots Mat- tres- ses Blan- kets Bed- ding Pil- lows Wash- basins Crock- ery Towels Brooms Pails Tubs Can- dles Soap

1

2

3

4

5

6

MEAL TICKET RECORD DIET HEALTH

1 Meal Ticket No.

Date

Diet

Health

2 Meal Ticket No.

Date

Diet

Health

3 Meal Ticket No.

Date

Diet

Health

4 Meal Ticket No.

Date

Diet

Health

5 Meal Ticket No.

Date

Diet

Health

6 Meal Ticket No.

Date

Diet

Health

Above form as illustration

CAMP COMMANDER’S REPORT[303]

For Week Ending 1906 CAMP NO.

Men Boys Women Girls Total

OCCUPANTS

As per Last Report

ARRIVALS This Week { Add to Above

Total

DEPARTURES

Ejectments

Left Camp

Sent to Hospital

Deduct this from Above } Total

TOTAL OCCUPANTS { Remaining in Camp

Regular MEAL TICKETS

Full Books Issued } Equals Tickets

Part Books Issued } Equals Tickets

Total Issued

Total Tickets Redeemed

Special DIET TICKETS Issued

Returned Cancelled

Special RAW FOOD TICKETS Issued

Returned Cancelled

HEALTH

On Sick List as per Last Report

Since Reported as Well { Deduct from Above

Addition to Sick List this Week

Total Sick in Camp

Cases Treated by Doctor { as per Last Report

““““ This Week

Total Cases Treated by Doctor

EMPLOYED

Found Employment This Week

Total Employed Living in Camp

Unable to Work

Sick List

Desire to Work

Total in Camp As Shown Above

Camp Commander.

Above form as illustration

REPORT FORM

REHABILITATION COMMITTEE

Daily Report for 1906

RECEIPTS PREVIOUS TO-DAY TOTAL TRANSPORTATION DETAILS LOAN ACCOUNT

Appropriations Comm. contribu- tion estimated Total loans to date

Loans Repaid Paid by committee Total repaid

Miscellaneous Estimated bal. due railroads Balance outstanding

TOTAL TODAY’S AVER- AGE PAYMENT FOR EACH CASE TOTAL AVER- AGE PAYMENT FOR EACH CASE APPROPRIATION ACCOUNT

Appropriations

DISBURSEMENTS Other sources

Tools Total

Household Disbursements

Business Balance available

Special Relief

Transportation

Miscellaneous

TOTAL

Balance on hand

STATEMENT OF APPLICATIONS FINALLY DISPOSED OF DAILY STATEMENT OF APPLICATIONS PENDING

KIND PREVIOUS TO-DAY TOTAL Waiting Registration

Waiting answers to correspondence

Tools Action deferred-housing, business, etc.

Household Waiting recommendation

Business Waiting approval by sub-committee

Special Relief Waiting approval by whole committee

Transportation Approved but checks not drawn

Miscellaneous Total cases pending in office

TOTAL Total cases pending in field

Total cases already disposed of

ACTION TAKEN

Total cases to date

Referred to others

MISCELLANEOUS INFORMATION

Refused

Not found No. of cases received yesterday from sections and Investigating Bureau

Withdrawn

Assisted Number of cases received yesterday from societies

TOTAL

Cases with checks drawn but not signed

NO. OF INDIVIDUALS Cases with checks signed but not delivered, and cases refused

PASTER[304]

REHABILITATION COMMITTEE

Date ____________ Recommended LoanGrant $ ________ for Household Special Relief Transportation Housing __________________

Date ____________ Approved LoanGrant $ _________ for _______________________________

Any conditions?

Check No. Signed

Transportation Request

Above form as illustration

CIRCULAR

F. W. DOHRMANN, CH. D. O. CROWLEY O. K. CUSHING JOHN A. EMERY JOHN GALLWEY C. F. LEEGE ABRAHAM HAAS

KATHARINE C. FELTON, SUP.

REHABILITATION COMMITTEE

SAN FRANCISCO RELIEF AND RED CROSS FUNDS (A CORPORATION)

GOUGH AND GEARY STREETS

The Rehabilitation Committee, from this time on, will separate its work under two distinct divisions; one established for a limited period and designed to meet the needs of self-supporting families, who cannot, within the means at their command, obtain necessary household furniture or secure homes suitable to live in; the other established on a relief basis, and designed to meet the needs of families who, on account of illness or other misfortune, are for the time being incapable of self-support.

Under Division One, applications for housing and household furniture will be considered.

(a) HOUSING: The Committee has arranged with several contractors to build four and five roomed cottages, with plumbing installed, at prices ranging from $300 to $800. Any self-supporting man or woman, who is the head of a household, and who, as the result of the disaster, is unable to obtain suitable housing accommodations at rent within his means, can arrange to buy one of these cottages. If he is unable to pay the entire cost, the Committee will make part payment, and when necessary can arrange that the other part may be paid by the purchaser in monthly installments. Not more than $50 in ready money is therefore needed in order to enable any family to take advantage of this offer, and the monthly payment on both house and lot will not exceed the ordinary rent. The Committee is also ready to help those who are building cottages according to their own plans, provided the total cost does not exceed $750. The Committee believes that many families would do well to avail themselves of this offer to obtain a house of their own at small cost. Applications will be received by mail only and should be directed to the “Housing Committee.”

(b) HOUSEHOLD FURNITURE. Applications will be received from families who are self-supporting and have suffered material loss from the disaster. The income and present resources must be insufficient to enable the family to get necessary household furniture within a reasonable time, without incurring burdensome debt. No application under this head will be received from anyone to whom the Committee has already made a grant. Applications will be received by mail only. Write for a blank to Gough and Geary streets. Mark envelope “Furniture Application.” No such applications will be received after January 31st, 1907.

Division Two is organized on the basis of relief. Applications will be received only from families who, through circumstances beyond their control, are incapable of self-support, and whose applications, even under normal conditions, would be received by any regularly organized relief society. No grants will be made to single persons capable of self-support, to families where the husband is earning practically the same wages as he did before the fire and is capable of supporting those dependent upon him, or to those who have made no plans for the future and who ask for money simply to meet the ordinary every-day expenses.

Anyone in need of relief should call at the offices between nine and ten any morning except Saturday. Applications for relief are not received by mail.

N. B.—After January 31st [1907], no application will be received under division one except for Housing, and no grant will be made to self-supporting families. This rule will be strictly adhered to.

KATHARINE C. FELTON Superintendent

APPLICATION BLANK[305]

No.

REHABILITATION COMMITTEE

San Francisco Relief and Red Cross Funds, Inc.

Dated 1907

Surname Date Address Rooms Rent

April 17th How long?

First Name Age Occupa- tion Earnings Per Week Physical condition Name Address

of Employer

Man

Woman

Children

Others in Family Other References

Insurance: Amount? Savings: Amount?

What companies? Real Estate: Value?

Other Property?

Attach two letters of reference. If possible one should be from a former landlord to whom you have paid rent for some time. If you are living in a permanent camp, one letter must be from the Camp Commander.

(OVER)

Above form as illustration

CIRCULAR LETTER OF INQUIRY

F. W. Dohrmann,

Chairman

D. O. CROWLEY

O. K. CUSHING

JOHN A. EMERY

JOHN GALLWEY

ABRAHAM HAAS

C. F. LEEGE

KATHERINE C. FELTON

Superintendent

REHABILITATION COMMITTEE

SAN FRANCISCO RELIEF AND RED CROSS FUNDS

A CORPORATION

GOUGH AND GEARY STS.

SPECIAL COMMITTEE ON HOUSING AND SHELTER

REV. D. O. CROWLEY,

Chairman

MISS A. GRIFFITH

DR. A. A. D’ANCONA

MR. JOSEPH C. QUEEN

MR.O.ALBERT BERNARD

San Francisco,

Dear

has made application to avail himself of the offer of this Committee to assist in the refurnishing of homes, an offer which you have probably seen in the daily papers, and has given your name to us as his principal reference.

In sending you this letter, the Rehabilitation Committee urges you to consider that the great majority of those who apply for relief are strangers to the Committee, and that it cannot deal with their applications either justly or quickly unless those who do know them are willing to consider themselves as in a sense trustees of this fund, and to share with the Committee some of the responsibility of its administration.

In this present investigation, the Rehabilitation Committee expects to rely largely upon the information it receives from the references of applicants, and therefore deems it especially important to emphasize at this time its need for accurate and full information. Anything that is written is regarded as entirely confidential.

O. K. CUSHING, Acting Chairman.

QUESTIONS

How long has Mr. .......... been in your employ? ..........

Wages per week at present? ..........

Is the work likely to be permanent? ..........

Are you in a position to state whether this applicant is temperate, honest, and of good character? ..........

Can you freely recommend the granting of this application? ..........

N. B.—Send reply in enclosed directed envelope.

RECOMMENDATION FORM

FORM FOR SPECIAL RELIEF

In duplicate, both copies to be forwarded to the Executive Officer. Issues to be made only to women and children in need; men only when sick and destitute. Following questions must be answered in every case.

CAMP

DATE 1907

SUPERINTENDENT OF SPECIAL RELIEF,

SIR:

I HAVE RECOMMENDED THAT THE FOLLOWING BE SUPPLIED:

Name of Applicant in full and Age Wages

Full Name of Parents or Husband or Wife If not Working, why?

Present Address Means of Support

Address Prior to April 18th, 1906 Number in Family

Occupation Relief Already Received from the Rehabilitation Committee

ARTICLES

Approved: Approved:

Executive Officer Camp Commander

Above form as illustration

REPORT FORM

BUREAU OF SPECIAL RELIEF HERBERT GUNN, M. D.

Supt. Bureau Special Relief

Department of Relief and Rehabilitation San Francisco Relief and Red Cross Funds GEARY AND GOUGH STREETS

Week Ending 190

REPORT OF SECTION

NO. ORDERS ISSUED NEW

NO. ORDERS ISSUED REPEAT TOTAL

NO. ORDERS DISCONTINUED

Are orders filled promptly and are articles of good quality?

(SIGNED)

Above form as illustration

MEDICAL SERVICE FORM[306]

Nº 1102 HERBERT GUNN, M. D. Supt. Bureau Special Relief

BUREAU OF SPECIAL RELIEF

Geary and Gough Streets

San Francisco, 1906

Section

Please call on

Address

Relief required

Remarks

Kindly return this paper with your report.

Reported by letter or in person

Refer to

Above form as illustration

ORDER FORM—A[307]

Date

ORIGINAL REPEAT BUREAU OF SPECIAL RELIEF ORIGINAL ORDER

No. Date

Surname

First Name: Man’s Woman’s

Address

Address April 18, 1906?

Number in family? Ages

Adult Males? Ages

Adult Females? Ages

Name Occupation Where Employed Amount per Week

Amt. Recd. from Rehab. Com. $ Date

How expended?

Insurance? Companies?

Savings Amount? Bank:

Real Estate: Value:

Location:

Other resources:

Residence Continuous in S. F. since April 18th?

Will require relief for:

Reason for requiring relief:

Physician attending? Paid?

Articles required:

Meat Order

Approved

Above form as illustration

ORDER FORM—B

BUREAU OF SPECIAL RELIEF Department of Relief and Rehabilitation San Francisco Relief and Red Cross Funds GEARY AND GOUGH STREETS

San Francisco, 190

Name

Address

Dear Sirs:

Please deliver to

the following articles

and charge to Bureau of Special Relief.

Cost Cost

Apples (dry), Potatoes,

Beans, Prunes,

Bread, Rice,

Butter, Salt,

Cocoa, Soap,

Coffee, Sago,

Condensed Milk, Sugar,

Eggs, Tea,

Flour, Pepper,

Macaroni, Candles,

Mush,

Total Total

Received above articles

Superintendent.

IF UNABLE TO DELIVER, NOTIFY THIS OFFICE AT ONCE

Above form as illustration

HOSPITAL REPORT SHEET

SAN FRANCISCO RELIEF AND RED CROSS FUNDS INCORPORATED HOSPITAL DEPARTMENT

Hospital Report for week ending 190...

Name of Hospital

Superintendent

No. Name of Patient Age Single Mar- ried No. of Chil- dren Occupa- tion Address Society, if any Admitted Diagnosis Condition when Admitted Discharged Cost of Main- tenance at $2.00 per day Remarks

Be- fore Af- ter Be- fore Af- ter Day Hour Provis- ional when adm’t’d Con- firmed (date of) Pulse Temp. Resp. Day Hour

I certify that the above is correct in every detail:

(Signed)

Actual size of sheet 16 x 21 inches.

Above form as illustration

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?

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.

1. Location:

a. April 18, 1906

b. Proposed location

Schedule of prior location per month Schedule of proposed location per month

2. Number of rooms

Number available for subletting

3. Rent $ $

(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

$ $

15. Total income of family from all sources $ $

16. Total monthly living expenses of family, aside from expenses of house

$ $

17. Margin of profit $ $

18. Can repay to Relief and Red Cross Fund, monthly $

Above form as illustration

APPLICATION FOR BONUS

CIRCULAR 2-B. FILE NO.

APPLICATION FOR BONUS

Thomas Magee, Chairman Land and Building Department, San Francisco Relief and Red Cross Funds, Union Square, San Francisco.

Dear Sir:—

Having been burned out of my home, situated on the land described in the diagram below, by the fire which commenced April 18, 1906, I hereby apply for a bonus from Relief and Red Cross Funds at your disposal to assist in rebuilding.

(Mark on plat description by streets, location in block, and size of lot.)

I am a citizen of San Francisco and was a resident thereof at the time of the fire.

At the time of the fire I was in possession of said property, and was and am now the holder of the record title, free of any incumbrance except as follows:

My family consists of

The kind and size of house I intend to build is as follows:

I intend to build by (State whether you will do your own work or whether you will

employ labor.)

Estimated cost of house,

Estimated number of rooms,

Burned residence address,

Present address,

Present occupation,

Name, Address,

References: {

(Please attach letters of reference from all persons whose names you use.)

Dated, (Signed)

San Francisco, Cal.,

, 1906.

[OVER]

Above form as illustration

LAND AND BUILDING DEPARTMENT. NOTICE[308]

CIRCULAR 1-B.

THE SAN FRANCISCO RELIEF AND RED CROSS FUNDS (a corporation) is prepared to receive applications for assistance from its Land and Building Department under any of the three plans following:

(1) BONUS: To any lot owner in the burned district a bonus of one-third the cost of a new house, bonus not to exceed $500, will be given to aid him in erecting a home. This bonus will be paid to the contractor as his last payment, and after the building is finished. If lot owner chooses to erect his home with his own hands, the value of the house will be estimated when it is finished and one-third its value will be given to the lot owner. The sum of $500,000 has been set aside for this purpose. This offer to remain open until October 1, 1906, unless fund is exhausted before that date. No more than one bonus to be paid to one person.

(2) PURCHASE (Cash or Installment): Cottages, two-story dwellings and flats will be built by the corporation and sold for cash or on the installment plan, and no interest will be charged on deferred payments. A small cash payment down and a percentage of total cost to be paid monthly. To illustrate: A home-seeker wishing to buy a $300 lot with a $600 house on it (containing four rooms and bath) can purchase it from the corporation at cost as follows: Monthly payments of $15 to be made for sixty months; 5 per cent of the total cost ($45) to be paid down, when a receipt will be given for the payments covering the first three months; then a payment of $15 a month to be made for the remaining fifty-seven months. Taxes will be paid by the corporation and charged to the purchaser. When the $900 and taxes have been fully paid, a deed will be given. The contract of purchase will be non-assignable. A sum not exceeding $2,500,000 will be set aside for this purpose. Any head of family who resided in San Francisco before April 18, 1906, and now engaged in some business or employment is eligible to apply, preference being given to those now living in tents.

(3) LOANS: Not exceeding $500,000 will be used in making loans to those—whether owners or tenants—whose places of residence in San Francisco were burned in the fire, such loans to be used in building new dwellings anywhere in San Francisco on a lot owned by the person to whom such loan is made, such loan to equal one-third of the cost of the building, not, however, to exceed in any case $1,000, and no more than one loan is to be made to any one person or family. Security for such loan is to be taken by way of first or second mortgage upon the building and lot if necessary, the borrower to pay 3 per cent net interest. This offer to remain open until the first day of October, 1906, unless this appropriation of $500,000 is sooner exhausted.

Applicants are required to use the blank provided for the particular kind of assistance desired in each case.

No applications will be received except by mail.

Applications will be investigated and acted upon as rapidly as possible, and in the order of their receipt.

Thomas Magee, Chairman Land and Building Department, UNION SQUARE, San Francisco.

APPLICATION FOR HOUSING GRANT

SUB-COMMITTEE ON HOUSING

APPLICATION

No. Date 1907

Surname Address Rooms Rent

At present

April 17thHow long?

First Name Age Occupation Earnings Per Week Physical Condition

Man

Woman

Children

Others in family

Name and address of present employer

How long working for present employer

Name and address of former employer

How long working for former employer

Attach two letters of reference. If possible, one should be from a former landlord to whom you have paid rent for some time. If you are living in a permanent camp, one letter must be from the Camp Commander.

Description of lot

What evidence of ownership can you give? Have you a deed?

Tax receipt? Contract for purchase?

Date when you bought lot

How much paid? How much unpaid?

What monthly installments do you pay?

Attach plan of contemplated house. (A drawing prepared by applicant,

showing floor plan and dimensions will answer)

Estimated cost of house Of lumber

Of hardware Of labor

Cost of plumbing and sanitary fittings Water connections

Sewer connections

What amount of the total cost of the house are you able to meet?

What amount do you ask from the Relief Funds?

(Sign your name here)

It is absolutely necessary for you to have a contractor’s or builder’s estimate of the entire cost of the house, specifying in detail the cost of building material and plumbing.

N. B.—Be sure to return this blank after it is filled out, and use the enclosed addressed envelope.

Above form as illustration