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a. ARE GOVERNMENT QUARTERS PROVIDED? (If "yes", disregard other questions in this section) [ ] YES  [X] NO
b. TYPE OF QUARTERS YOU OCCUPY [ ] ROOM
[ ] APARTMENT [X] HOUSE
c. QUARTERS ARE RENTED [] FURNISHED
[] UNFURNISHED [] PARTIALLY FURNISHED (Explain under remarks)
d. DO YOU OCCUPY QUARTERS WITH ANY OTHER MEMBER OF THE UNIFORMED SERVICES? 
[] YES   [X] NO
e. STATE AMOUNT OF MONTHLY RENT (If answer to "d" is "yes", state your pro-rata share & not the total cost to all) $^[[200.00]]
f. TYPE OF HEAT [] ELECTRICITY [] WOOD 
[] COAL  [] GAS  [X] OIL  [] OTHER (Specify below) ^[[KEROSENE]]
g. MONTHLY COST OF UTILITIES (Give year-round average)
[[2 column list]]
UTILITY | COST

ELECTRICITY | $ ^[[5.00]]
GAS | $ [blank line]
KEROSENE | $^[[1.00]]
TELEPHONE | $^[[2.00]]
FUEL OIL | $^[[8.00]]
COAL | $^[[1.00]]
WOOD | $^[[—]]
WATER | $^1.00]]
TRASH & GARBAGE REMOVAL | $^[[1.00]]
POLICE PROTECTION | $^[[—]]
FIRE PROTECTION | $^[[—]]
OTHER (Specify under n) | $ ^[[—]]
(If answer to "d" is "yes", state only your pro-rata share and not the total cost to all)
h. SIZE OF QUARTERS OCCUPIED
ROOMS [blank]    BATHS [blank]

4. QUARTERS
i. ARE YOU OBLIGATED BY LAW OR LEASE FOR MAINTENANCE AND REPAIRS? (Exclusive of expenses reported under m.)
[] YES   [X] NO
If "YES", GIVE AVERAGE MONTHLY COST AND PERIOD OVER WHICH SUCH COST WAS COMPUTED.
COST $ [blank line] PERIOD: [blank line]
(If answer to "d" is "Yes", state only you pro-rata share and not the total cost to all)
j. ARE YOU REQUIRED TO MAINTAIN INSURANCE ON RESIDENCE? [] YES   [X] NO
IF "YES" STATE MONTHLY PREMIUM $ [blank]
(If answer to "d" is "yes", state only your pro-rata share and not the total cost to all) 
k. DO YOU HAVE A LEASE ON YOUR PRESENT QUARTERS? [X] YES   [] NO
IF "YES", FOR HOW LONG? ^[[—]]YEARS ^[[3]] MONTHS.  DO YOU HAVE PRIVELEGE OF RENEWING LEASE WHEN IT EXPIRES? [X]YES  []NO
l. IF TYPE AND/OR SIZE OF QUARTERS ARE BEYOND THE NEEDS OF YOU AND YOUR FAMILY, STATE REASON OTHER QUARTERS ARE NOT SOUGHT.
[blank line]
m. INITIAL EXPENSES FOR PRESENT HOUSE
   (Explain each entry under remarks)
[[2 column list]]
SCREENS | $ [blank line]
NECESSARY REPAIRS UPON OCCUPANCY | $ [blank]
ELECTRICAL INSTALLATION | $ [blank line]
PLUMBING INSTALLATION | $ [blank line]
GAS INSTALLATION | $ [blank line]
SHELVING | $ [blank line]
OTHER (Specify under n) | $ [blank line]
(If answer to "d" is "yes", state only your pro-rata share and not the total cost to all)

n. REMARKS (Include here any other costs of quarters not called for above which you have experienced. Explain fully. If answer to "d" is "yes", state only your pro-rata share and not the total cost to all)
^[[Station Allowance $4.10/Day]]

5. ADDITIONAL ALLOWANCES
ARE YOU ENTITLED TO ANY ALLOWANCES FOR QUARTERS AND SUBSISTENCE OTHER THAT YOUR BASIC ALLOWANCES AND STATION ALLOWANCES? [such as voucherable quarters maintenance allowances, mission allowances (exclusive of representation allowance), allowances from State Department, allowance from United Nations, etc.] []YES  []NO
(If "Yes", state amount, type of allowance, and source)  [blank line]
REMARKS (All other data pertinent to cost of living. Use additional blank sheets, if necessary)  [blank line]
RATE OF EXCHANGE USED IN CONVERTING COSTS ON THIS FORM TO U.S. DOLLARS
NO. [blank line]  
UNIT (e.g. pesos, ? , francs, guilders, ?)
[blank line] TO THE U.S. DOLLAR

I CERTIFY THAT THE INFORMATION APPEARING HEREON IS TRUE, COMPLETE, AND CORRECT TO THE BEST OF MY KNOWLEDGE
DATE [blank line]
SIGNATURE ^[[BO Davis Jr]]

511-325-ARMY-AG ADMIN Cen-Japan-6M
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