Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
EXHIBIT C FAMILY ECONOMIC INVENTORY - <br />Date <br />NAMEgg Mo Cloud RACE B SEX F BIRTHDATE July 4, 1914 <br />ADDRESS e e PHONE <br />How longlive - <br />in county? o0 ear Fl <br />.In orida? o ears <br />Number f persons in family Ages of children 1n home <br />Other dependents <br />INCOME net <br />NAME OCCLIPATION - FMPI nYFR mnNT141 Y SAI ARY <br />Hazel <br />housewife <br />$ 152.00 <br />17-00 <br />Dr. Ame & <br />Services <br />5.00 <br />$ <br />I ntrc iivLurie MAL I AL MUM <br />$ 152.00 <br />ASSETS <br />Bank Account $ None Property -Home Value $ None Car <br />Real Estate $ Year 1968 <br />Other Model Ford <br />EXPENSES <br />Rent or Household <br />House Payments $ 93.00 Utilities 17.00 Food $ 42.00 Car $ <br />Clothing $ Other $ <br />INSURANCE <br />Hospital None <br />Name and Address Policy # Group # Premiums <br />HEALTH & ACCIDENT None <br />Name and Address Policy # Group # Premiums <br />LIFE & OTHER Life of Georgia 3.85 weekly <br />Premiums <br />INDEBTEDNESS -Balance <br />Inctallmantc nail to Cnmmndity nua Mnnthly Aavman+c <br />Babcock <br />T.V. <br />135-00 <br />17-00 <br />Dr. Ame & <br />Services <br />5.00 <br />u1ntK utuia iozai monznFy txpense <br />I hereby certify that the above statements are true and t at I am unable to pay for <br />the cost of medical treatment or the cost of hospitalization recommended. <br />DATE <br />Signature of Patient or Guardian <br />Approved Disapproved <br />REMARKS ON REVERSE SIDE <br />OF THIS FORMgnature of Interviewer <br />HF&S:HS1:jb:1000 <br />JL 71976Fir 26 ..�";5 <br />