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1919]
16
The following is the inquiry form at present in use in the Borough. It
shows that every care is taken to obtain an exact return of the means of the
family requesting assistance. The information has been invariably and gladly
given by the parents.
Milk (Mothers and Children) Order, 1919]
no
re Mrs of
No in Family
Ages: Over S yrs ; ; ; ;
Under 5 years (and date of Birth)
Baby: Breast-fed or bottle-fed.
Means: (Weekly Income)
Earns
(i) Father ' Occupation
Gives Mother
(ii) Other Sources (iii) Mother
Weekly Expenses:
Rent Doctor
Gas ... Boot Club
Coal Clothing Club
Insurance Total
Balance for people for
Milkman of
Milk used prior to application pints daily.
Received milk from Council since
Attends any Borough's Centres: (i) Yes. (ii) No.
Nature of help therefrom (if any)
Relief from (I) Parish i. Milk
(2) Elsewhere ii. Other food
Remarks :
I declare that the foregoing statement as to my family and income is true in every particular.
Date Father's Signature
Quantity: For Mother pints: for child(ren) pints.
Contribution by applicant towards milk supply per pint.
Period
Certified a necessitous case by
Medical Officer of Health.
Hon. Secretary of
Date Centre