In response to Helen's question: Although I can't help with this specific request, the following is a related issue to her question. I found it, printed in an old newspaper in the Miller county, Missouri area. It is the actual questions that they were supposed to answer. From “The Iberia Sentinel”, Iberia, Missouri, Thurs, 12 Sep 1935, Vol 30 No 51, APPLICATION FOR OLD AGE PENSION QUESTIONS: 1. Name: sex 2. Present address 3. Maiden name if you are a married woman or a widow. 4. Date of Birth 5. Place of Birth 6. Which of the following documents do you have which indicate the date of your birth? If document is not in your possession, indicate where it may be found. Birth certificate Marriage license. (For Women) birth certificate of one of your children. Church record or other evidence, specify. 7. Are you a citizen of the united States: 8. If a citizen, check manner in which citizenship was acquired. Born in the United States of native born parents Born of naturalized foreign born parents. If so, give father's name: date naturalized. Place Marriage to a citizen. If so, give name Place of birth: date naturalizaed. Place Naturalized foreign born. If so, give date naturalized. Place If foreign born, when did you enter the United States:Where: 9. Give your residence for the period since August 27, 1926. 10. Present address 11. First, second, third, fourth, fifth,sixth, seventh, and eighth previous address. 12. If absent from the state for ninety days or more at any time since August 27, 1926, give the item place and reason. 13. Give dates of marriage (If married more than once list most recent first.) Name husband or maiden name of wife and present address. 14. Are you now living with husband or wife: 15. If divorced, give date of divorce, place, reason. 16. If widowed, give date of death of spouse; place. 17. If seperated, give date of separation. 18. What are your present living arrangements? 19. Is a private residence owned by you or your husband or wife? 20. Is private residence rented by you or your husband or wife? 21. If so give monthly rental. 22. Is rent fully paid? 23. If not,give amount delinquent. 24. Number of rooms; relationship to other persons living with you. 25. Live with parent or child. If so, give name and relationship of head of family to you. 26. Room or board with other relative or friend. If so, give relationship, if any, or head of family to you; amount of room or board paid per month. 27. In a state, city or county home. (Name institution) 28. In a private, charitable or benevolent home for the aged. 29. Name of institution. 30. Date of admission 31. Amount paid on admission 32. Required payment per month. 33. Are you an inmate of any prison, jail, insane asylum or any other public reform or correctional institution? If so, give name and address of such institution. 34. Source of income. (With amount for past year and estimated amount for next year to be given) 35. Give name of most recent employer. If any. 36. Address 37. Date and duties of employment 38. Give usual occupation or trade. 39. Give average yearly earnings while engaged in your usual occupaton. 40. Living expenses. If living with others, give only proportionate share of total expense. for food, clothing, rent or property expense, fuel, light, insurance, board, medical and dental care and other expense, also whether the expenses indicated above are for yourself alone or yourself and husband or wife. 41. List all living children and living parents. REAL PROPERTY OWNED 42. Do you and or your husband or wife own or hold title to any property? 43. If so, in whose name? 44. If so, give number of parcels: assessed value. 45. Do you have any interest in property under land contract or under 99 year leasehold? Yes, No. 46. Have you or your husband or wife disposed of any real property which you owned within the past two years? Yes. No. 47. If so, give location and type of property. 48. Transferred to; date of transfer. 49. Reason for transfer. 50. Assessed value. PERSONAL PROPERTY OWNED BY YOU OR YOUR HUSBAND OR WIFE 51. Deposits in banks, building and loan associations, savings societyies, or postal savings accounts; stocks, bonds and other securities. 52. Do you and or your husband of wife own or hold title to any stocks, bonds and other securities? 53. If so, give present market value; interest or dividends received in past year. 54. Amount due to you on mortgages and notes which you hold and amount of other debts owed to you, with amounts due you, type of loan, mortgage, interest, taxes, etc. 55. Cash on hand, in safety deposit box, or elsewhere. OTHER PERSONAL PROPERTY OWNED 56. automobile, horses, mules, cattle, and livestock, tools of farm equipment and other personal property. 57. What debts (other than on mortgages on real estate) do you have outstanding with details.? INSURANCE 58. Do you have any life insurance policies at present? 59. Who paid premiums for past year? 60. Do you have any life insurance policies with surrendered values that have lapsed? 61. If so, give date of policy and when lapsed. 62. Has any policy on life of applicant been surrendered for cash or otherwise disposed of during past year? 63. If so, give particulars HEALTH 64. Are you in good health at present? If not, give present disability. Attending physician 65. Have you consulted a physician within the past year? Yes.No. If so, for what reason. 66. Name of physician. 67. Date of most recent physical examination 68. Name of physician WAR VETERAN 69. Are you a war veteran? 70. Are you a widow of a war veteran? 71. Are you a parents of a war veteran? 72. If a widow or parent, name each veteran and war service. ELIGIBILITY FOR OTHER AID AND BENEFITS 73. Are you eligible for admittance, but not living, in a fraternal church, or benevolent home? 74. If so give name and address of home. 75. Reason for not accepting admittance into the home. 76. Are you eligible for any other aids, benefits, annuities, or pensons, not public or private charity, which you are not now receiving, such as insurance annuitites, blind pensions, etc? 77. If so, give name of organization and address 78. Amount of aid 79. Reason for not accepting the above mentioned benefits. 80. Please give the name, etc, of three people, not relatives, who have known you for ten years or more. Kathy Bowlin