State of California I I I } Department of social Welfare
Application for Old Age Security
o..v.   m
STATE OF CALIFORNIA State No.i^L	
joy ,,*ilwi»*t.O .*t«ibb« tsfifons of avofn uoy V n  bluorf?
-_■ v  ti' eeuaasd uoy Driirbse'.
County of Los Angeles County No..
•■
To the Honorable Board of Supervisors:
1
ftfk   A-
A     1 J±             - f A.      /./
____
PRINT OR TYPE NAME IN FULL
City
/'   •  //     y  &
Former State No. if a transfer or reapplication.
ew eu of et_»sT me
~    -      Av :0't f av, 0 m /h-y-
, residing at       /     &     A
Street number or R. F. D.
.89.   V
., County of »gj ;    *' * , California
herewith apply for Old Age Security under provision of Chapter 1, Division 3, Welfare and Institutions Code.
I believe I am eligible for Old Age Security, to wit:
1. I have attained the age of 65 years, or will be 65 years of age within 60 days from this date. C
Birth date.
2. I have resided in the State of California for at least one year immediately preceding the date of this application, and for at least 5 years within the 9 years
immediately preceding this application. oa»i uov f;  e>*»e.on.  nio taoa A.
3. I  have not made any assignment of property  in order to qualify for Old Age  Security.
.bettoqe.  yUvjo.Vfl.ig- uoy *._•;*.■
A Property: In addition to my home, my real and/or personal property holdings do not exceed the limitations specified in (a) and (b):
"(a) Real property which I  agree to use to meet my needs. Such property, and that owned with my spouse, does not have a net county assessment value
in excess of $5,000."
?     "(b) Real or personal  property which   I own  and  hold  as a  reserve.  Such property does not have a net value in excess of $1,200."
5. I do not have sufficient income to meet my needs.
S y, * y     /' 4 .. m .__;   ? J f *y i / /   Aki & - * A!**
6. My spouse's name is Z.   *'* aft — , rJ   ** 11     Address
r /- A/A >
7. I h»™        S C   if/ j   it        ['""Cf children.
I
8. I agree to assist, to the best of my ability, in disclosing my financial condition and that of my spouse and to give all information necessary to establish |
eligibility for aid under this chapter.
- \
state of California County of Los Angeles
I solemnly swear or affirm that the statements made herein are true and correct to the best of my knowledge and belief and that I will notify the county
authorities promptly of any change in my condition or financial affairs. ono*©..  t  trrav
•!•-.. A&*\Z «*Ht   .o    li|lMWfl 4J
NOTE—When the applicant cannot sign his
name, the signature of two witnesses
to his mark must appear.
' SIGNATURE OR MAfcK OF APPLICANT
m$fi,n/   y    }   Hiittrf
!    __<j_
M/#.K OF APPLIvtA
Subscribed and sworn to before me this  f Amt — day of \
7 u* i*. - -____ ,. A 3     i^-T:^^   a-aaa.,,.4
 WiiiiMtrmmYtopnTVWKK-   -—-      «LT_i!siI0 MT~ _ J Z   ~y        ADDRff^
.Name J. „... Title £!^5^£^  '-V  J-/ Ia1/jLL< Art    / /i   /* tJ
Signature of person qualified to A 7/ff     Ct& #gg ', ST ft.., A     /).{   4 tV
acknowledge an affidavit WITNESS TO MARK ADDRESS       "p>
If you are not satisfied with any decision in connection with your application, or if you wish to protest delay  in  action on  your application, you  may
request a hearing before the board of supervisors; or you may appeal  directly to the State DePartmentME_T%ffiF(9t^A^ffi
°fthiSsheet- 2711   BEVERLY  BLVD.
READ THE IMPORTANT NOTICE PRINTED ON THE BACK OF THIS SHEET ._       ._._,., _..   __.    _.
Zm Ag 200 76A658 (Co. Rev. 1-62) ft «-OS ANGELES 57,  CALIFORNIA