1971 C E N S U S
H Form For Prh
To the Head (or Acting Head) of the Household
Please complete this form in ink or ballpoint pen and have it ready for collection on Monday, 26th
April. Please consult the separate notes, where these.are mentioned. If you need help, ask
the enumerator.
The enumerator is entitled to ask you any questions necessary to help him to complete or correct
the form.
The information you give on the form will be treated as CONFIDENTIAL and used only for compiling
atistics.. No information about named individuals will be passed by the Census Office to any
o er Government Department or any other authority or person. If anyone employed in taking the
census improperly discloses information you provide, he will be liable to prosecution. Similarly
you must not disclose information which anyone (for example, a visitor or boarder) gives you to
enable you to complete the form.
The legal obligation to fill in the whole form Vests on YOU,but each person who has to be included
is required to give you the information you need. However, anyone who wishes can ask the
enumerator or local Census Officer for a personal form which can be returned direct to the enumerator or local Census Officer and then you need answer only questions Bl and 85 for that person.
%
PLEASE TAKE NOTE
There are penalties of up to f50 for failing tO comply with the requirements described above,
for giving false information.
When you have completed the form, please sign the declaration at the foot of the last page.
or
A L RENNIE
Registrar Generat
Census Office
Ladywell Road
EDINBURGH
~~
~
Answer questions Al-A5 about your
household's accom'modation and then ans1
questions Bl-B24 overleaf and if approprií
answer questions CI-C7,
Al
How do you and your household occupy your
accommodation 7
A3
How many rooms are there in your
household's accommodation ?
1
As an owner occupier (including purchase
by mortgage)
2
By renting it from the Council, New Town,
or SSHA
Do not count
Small kitchens less than 6ft. wide,
bathrooms and toilets,
sculleries not used for cooking,
closets, pantries and storerooms,
landings, halls, lobbies or recesses,
'offices or shops used solely for
business purposes.
3
4
0 As an unfurnished letting from a privafe
landlord or company
0 As a furnished letting
'
n some other way
(Please give details, including whether
furnished or unfurnished)
..................
Note
A large room divided by a sliding or fixed partition
should be counted as two rooms.
A room divided by curtains or portable screens chould
be counted as one room.
..................................................
A4 !.
Note: If the accommodation is occupied by lease
originally granted for more than 31 years, tick
'owner occupier'.
How many cars and vans are
normally available for use by you
or members of your .household
(other than visitors) 1
A2
Does your household share with anyone else the
use of any room, or hall, passage, landing, or
staircase 1
Include any provided by employers if normally
available for use by you or members of your household, but exclude ,vans used solely for the carriage
of goods.
YES
o No
If None, write 'NONE'.
...................
ISUS - SCOTLAND
Form For Private Households
A household comp
S
(who may or may not be related) living at the same address with common
housekeeping. Persons staying temporarily with the household are
included
ion on Monday, 26th
(ou need help, ask
complete or correct
;ed only for compiling
:ensus Office to any
nployed in taking the
vosecution. Similarly
ioarder] gives you to
To be completed by enumerator
C.D. No.
I
I
E.D:No;
Form No.
I
i
i
If sharing with another household :-
has to be included
wishes can ask the
direct to the enumerd B5 for that person.
10
UI
Hall. staircase, passage, etc., shared only/not only* for entry to accom.
modation.
*dele te whichever is inapplica ble.
........................
Number of rooms shared.
; described above,
Ref.
or
' the last page.
L
L RENNIE
Registrar General
~
t your
id then answer
I if appropriate
Where boxes are provided answer by putting a tick in
the box against the answer which applies. Forexample,
if the answer is 'YES':
YES 0 NO
a
PLEASE WRITE-IN INK
ir
..................
A5
Has your household the use of the following amenities on these premises?
a A cooker or cooking stova
with an oven
ide,
b A kitchen sink permanently
S,
ses,
c
ig
or fixed partition
7s.
table screenschould
U
d
...................
doyers if normally
ibers of your houseIlely for the cafljage
2
3
I
2
Afixed bath or shower
1
permanently connected t o a
water supply and a waste pipe
3
2
3
d A hot water sÜpply (to a
e A flush'toilet (W.C.) with
entrance inside the dwelling
2
3
I
2
YES
NO
- for use also by another household
'n
YES - for use only- by- this household
.
.
u
u
u
YES
0
- for use ako.by another household
NO
- for use only by this h o u s e h o x
YES - for use also by another household
YES
NO
YES
YES
NO
- for use only by this household
- for use also bY another household
n YES - for use only by this household
u YES - for use also by another household
0
NO
- for use only by this household
YES - for use also by another household
YES
1
2
3
1'
0
0
1
3
f A flush toilet (W.C.)with
entrance outside the dwelling
YES - for use only by this household
1
connected to a water supply and
a waste pipe
washbasin, or kitchen sink, or bath,
or shower) from-a heating appliance
or boiler w h i c h is connected to a
piped water supply
'e
OR BALLPOINT PEN
0
NO
PLEASE TURN OVER TO PART Btb
-
PART
Complete a line in Part B for every person present, that is every j
a spends Census night 25/26 April 1971 in this household
or b joins this household on Monday 26 April and has not been indu
-
Forany other person who usually lives in this household complete a line in Part C on the back page.
Bl
Fill in this column first for
every person present.
(see note above)
62
Write the date of
birth of the
person.
Write name and surname.
Begin w i t h the head of the
household (if present),
For a baby who'has not yet
been given a name write
1st person
63
Write
the sex
o f the
person,
(M for
male,
F for
fem a le).
B4
If the person usually lives here,
write 'HERE'.
If not, write the person's usual
address.
For boarders write 'H ER E' only
if they consider this their usual
address.
For students and children who
are away from home during
term time give their home
address.
For persons with no settled
address write ' N O N E'.
BLOCK CAPITALS PLEASE,
B5
Write 'HEAD' for the head of
the household and relationship to the head for each of
the other persons: for exam p I e 'Wife', 'Son',
'Daughter-in-law', ',Visitor',
'Boarder', 'Paying Guest'.
Month Year
2nd person
Month Year
3rd person
Month Year
4th person
Wonth Year
5th person
Wonth Year
6th person
Month Year
If there are more than six persons present continue on a new, form.
(The enumerator will supply you with one if he has not already done so.)
2
y person who
:ludedas present on a Census form elsewhere.
B6
Write 'SINGLE',
'MAR RI ED',
'WIDOWED' or
'DIVORCED' as
appropriate.
If separated and
not divorced
write 'MARRIED'.
5
B7
D i d the person have a job last w e e k (the w e e k e n d e d 24th
April 1971) 7 (see note 87)
Tick box 1 if the person had a job even if it was only part-time
or if the person was temporarily away from work, o n holiday,
sick, on strike, or laid off.
If the person did not' have a j o b tick whichever of boxes 2, 3,4
or 5 is appropriate; if box 5 is ticked state the reason; for
example 'Housewife', 'Student', 'Permanently sick'.
This question neednot be answered for children under 75 years
of age.
I
YES
2
NO
3
4
5
u
NO
NO
0
NO
88
Wjll the person b e a
student or pupil
attending full-time
at an educational
establishm e n t during
the term starting
April/May 1971 1
(see note 88)
- intending t o seek w o r k but sick
- w h o l l y retired
- n onamely
t seeking w o r k for some other reason,
YES
3
4
NO
5
NO
children uoder 75
years of age.
a Born in
0 YES
u
u
NO
NO
- n o t seeking w o r k for some other reason,
namely
..........................................
1
2
3
4
5
NO
NO
-
No
2
3
4
5
1
2
3
4
5
NO
u
No
0
NO
NO
u
NO
Born in
YES
0 N O - seeking w o r k or waiting t o take up j o b
NO - intending to seek w o r k but sick
0
NO
NO
-
w h o l l y retired
- not seeking w o r k f o r some other reason,
namely
.......................................... .
u
Wales (incl.
Mon m outhshire)
orb
Born in
(year)
Scotland
(country)
Northern
Ireland
........................(year)
a Born in
England
Scotland
Wales (incl.
M o nmouthshire)
YES
u
Northern
I reland
or b
No
.................................
and entered U.K.in.. ......................
Born in
-
u
Scotland
................................(country)
and entered U.K. in
- seeking w o r k or waiting t o take up j o b
- in a job at some time during the week
.:..............................
0YES
t
1
2
3
4
6
(country)
Northern
Ireland
0England
- in a j o b at some time during the week
..........................................
u
Scotland
and entered U.K. in ........................ (year)
namely
- n onamely
t seeking w o r k for some other reason,
........................
a Born in
NO
NO
0Northern
Ireland
Wales (incl.
Mon mo uthshire)
orb
- w h o l l y retired
- n o t seeking w o r k for some other reason,
- intending t o seek w o r k but sick
0 NO - w h o l l y retired
Wales (incl.
Mo n mouthshire)
................................
YES
(year)
u
a Born in
England
..........................................
YES
or b
Born in
(country)
England
and entered U.K. in
w h o l l y retired
- intending to seek w o r k but sick
Northern
Ireland
................................
and entered U.K. in ........................
YES
- n onamely
t seeking w o r k for some other reason,
0YES - in a j o b at some time during the week
0N O - seeking w o r k or waiting t o take up j o b
Wales (incl.
Monmouthshire)
Born in
u
..........................................
1
Scotland
a Born in
0 YES - in a j o b a t some time during the week
0N O - seeking w o r k or waiting t o take up j o b .
0N O - intending to seek w o r k but sick
u
England
orb
- in a j o b at some time during the week
- seeking w o r k or waiting t o take up j o b
- intending t o seek w o r k but sick
- w h o l l y retired
Wales, Scotland a n d Northern Ireland).
This question need
...........................................
1
2
or
b If the person was born in another country, wtite
the name of the country (using the name by w h i c h
it is known today) and the year in w h i c h the person
first entered the IJnited Kingdom (that is England,
not be answered for
- in a j o b at some time during the week
- seeking w o r k or waiting t o take up j o b
89
a If the person w a s born in Scotland or England or
Wales or Northern lreland tick the appropriate box.
(year:
n
Scotland
.
0 Northern
Ireland
a Born in
England
n
U
Wales (incl.
Monmouths hire)
YES
(country:
orb
................................(country)
(year)
and entered U.K. in ........................
Born in
3
PLEASE TURN
1971 CENSUS 'FORM
NOTES
B1O
Write the country of birth of:
These notes are to help you answer sdme of the questions in Part B
(for persons present). In cases where they also apply to Part C (absent
persons) this is shown in Part C.
a the person's father
b the person's mother
If you have any further difficulty with these, or any other questions,
please ask the enumerator about them w h e n he calls to collect your
form.
This question should be answered
even if the person's father or
mother is no longer alive. (If
country not known, write 'NOT
KNOWN'.)
Give the name by which the
country is known today.
87
Job last week
Ajob means any w o r k for.payment or profit. In particular it includes:
(a) w o r k on a person's own account
(b) part-time work, even if only for a f e w hours, such as jobbing
gardening or paid domestic w o r k
a Father born in (country)
(c) casual or temporary w o r k of any kind (for example seasonal work,
week-end w o r k and vacation w o r k by students)
(d) unpaid w o r k in a family business, for example a shop or farm.
b Mother born in (country)
Unpaid work, other than in a family business, does not count as a job.
W
s
5
a Father born in (country)
I
E3
3
b Mother born in (country)
W
o
I
I-
o
i
B8
Students
Do n o t count as full-time students people who are:
(a) on day release from w o r k to attend school or college
(b) attending night school only
(c) attending an educational establishment provided by employers,
such as an apprenticeship school.
-I
a Father born in (country)
4
O
o
a
W
9
W
b Mother born in (country)
a
f?
I
8
a
a Father born in (country)
W
m
e
B I 5 Employer's name and business
Describe the business fully and try to avoid abbreviations or initials.
General terms such as 'manufacturer', 'merchant', 'agent', 'broker',
'factor', 'dealer', 'engineering', are not enough by themselves and
further details should be given about the articles manufactured or
dealt in.
For civil servants, local government officers and other public officials
give the name of the Government department, local authority or
public body and the branch in which they arë employed.
For people employed solely in private domestic service write 'PRIVATE'
in answer to this question.
For members of Armed Forces see special note overleaf.
b Mother born in (country)
B I 6 Occupation
Full and precise details of occupation are required.
a Father born in (country)
b Mother born in (country)
If a person's j o b is k n o w n in the trade or industry by a special name
use that name.
Terms such as 'scientist', 'technician', 'engineer', 'machinist', .'fitter',
'foreman', 'checker' should not be used by themselves. &ater
detail is required as for example :woodworking machinist, civil engineer, toolroom foreman.
For civil servants, local government officers and other public officials
give their rank or grade.
a Father born in (country)
b Mother born in (country)
B I 7 Self-employed
'Self-employed, employing others' means having one or more employees other than 'family workers'. A 'family worker' is one who
lives in the same household as the employer and is related to him.
Where a person employs 'family workers' only, a tick should be put
against 'self-employed without employees' (but any 'family worker'
should b e recorded as 'an employee').
OVER TO THE NEXT P A G E 4
f
f
BI8 Apprentices, etc.
Answer this question only for a person who is undergoing training for
a period fixed in advance and leading to recognition as a skilled
worker or technician or to a recognised technical, commercial or
professional qualification or managerial post.
Do not answer this question for a young person undergoing probationary training who has not yet entered into formal apprenticeship.
i
i
i
B20 Place of work
lii
For people who do not work regularly at one place or who travel during
the course of their work (for example, sales representatives, seamen
and some building and transport workers) :
if they report daily to a depot or other fixed address give that
address;
y)
(b) if they do not report daily to a fixed address write 'NO FIXED
PLACE.
For people such as building workers employed on a site for a long
period give the address of the site.
For dock workers give the name and address of the dock or wharf at
which they are usually employed.
B21 Means of transport
If the person uses different means of transport on different days give
the means used most often.
Do not use terms such as 'public transport' or 'private transport' but
give the actual means used, for example, 'train', 'bus', 'car', 'bicycle'.
SPECIAL NOTE FOR MEMBERS OF ARMED FORCES
At B I 5 (or, if appropriate, C5) give arm and branch of service.
At B I 6 (or C6) give rank or rating only.
Questions B I 7 (or C7), B I 8, B I 9 and B22 need not be answered.
E
1
I
i]
Answers should be writ1
the person's name appei
BI1
Was the person's usual address
one year ago (on 25th April
1970) the same as that shown by
the answer to question B41
Write YES or 'NO'.
If no, write also the usual address
on 25th April 1970.
ia
!I
li
1:
For a child now under one year of
age, write 'UNDER ONE'.
.1
I
I
I
I
1;
BLOCK CAPITALS PLEASE
on the line on which
in column B I
BI2
Was the person's usual address
five years ago (on 25th April
1966) the same as that shown by
the answer to question B I 1 7
BI 3
Has the person obtained any of the
following 1
*,
For a child now under five years of
age, write 'UNDER FIVE'.
's
f Any other professional ,or'vocational qualifications
c Teaching qualifications
If so, give full details of all such,qualifications in the order i n which they were obtained, even if
not relevant t o the present job or if the person is not working.
Please check these details by asking each person about his qualifications.
If none; write 'NONE'.
This question need not be answered for persons under 18 or retired persons over 70.
This question need not be answered f j r
children under 75 or retired persons .
over 70.
BLOCK CAPITALS PLEASE
d Degrees, diplomas or other educational qualifications
e Graduate or corporate membership of professional institutions
a H.N.C. or H.N.D.
b Nursing qualifications
G.C.E. 'A' level
Higher School Certificate (HSC)
Higher grade of Scottish Certificate of
Education (SCE)
Higher grade o f Scottish Leaving
Certificate (SLC)
Ordinary National Certificate (ONC)
Ordinary National Diploma (OND)
Write 'YES' or 'NO'.
If no, write also t h e usual address
on 25th April 1966.
B I4
Has the person obtained any of the following qualifications since reaching the age of 18 ?
Qualification
Award ing lnstituti o n
Major Subject or Subjects
L
ievei vei or HSC
I
SCE higher or SLC higher
2
3
u
ONCorOND
4
None ofthese
I
~ ~ ~ ' ~ ' i e v HSC
e i o r
2
SCE higher or SLC higher
3
ONCorOND
4
Noneofthese
.
*
ievei leve lor HSC
I
2
3
u
u
4
SCE higher or SLC higher
ONC~~OND
3
u
u
u
ONC~~OND
4
0
N o n e o f these
1
2
~ ~ ~ ' ~ ' i e v HSC
e i o r
SCE higher or SLC higher
I
GCEW level or HSC
2
SCE higher or SLC higher
3
4
GCE 'A'
level or HSC
2
SCE higher or SLC higher
4
.
.
0O N C ~ ~ O N D
0 None ofthese
I
3
.
None ofthese
u
..
.
..
ONCorOND
I
I
Noneofthese
s1
i
4
5
PLEASE TURN OVER TO
The remaining questions in Part B do not apply to children under 15 years of age.
Answer questions B I 5-91 7 in respect of the main employment last week,
or of the most recent job if retired or out od work.
I
For persons who have never had a job and for a housewife who did not have a job last week write 'NONE'at B15.
B15
What was the name and business
o f the person's employer (if selfemployed, the name and nature of the
person's business) ?
(see note B15)
B16
a What was the person's occupation?
Was the person
Give full details. (see note B I 6)
an employee,
or
self-employed
employing others
(see note 817)'
b Describe the actual work done in
that occupation.
Give the trading name if one was usea!
or
self-employed
without employees 1
a Nameof
business
a Occupation
C
$
k
Q
b
Nature of
business
1
An employee
2
Self-employed
em ployi n g others
(see note B17)
3
Self-employed
wit ho ut em p loyees
1
An employee
2
Self-employed
employing others
(see note B17)
3
Self-employed
without employees
1
An employee
2
Self-employed
employing others
(see note 817)
3
Self-employed
without employees
1
An employee
2
Self-employed
em ploy ing others
(see note 817)
3
Self-employed
without employees
1
An employee
2
Self-employed
employing others
(see note B17)
b Description of work
a Occupation
b Description of work
a Occupation
b Description of work
a Occupation
b Description of work
a Occupation
b Description of work
elf-employed
without employees
a Occupation
b
1
An employee
elf-employed
employing others
(see note 817)
Description of w o r k
3
6
b
61 8
B17
Self-employed
without employees
For pc
If the person is an apprentice
or trainee, write
'Ap pre nt ice',
'Art icIed c Ier Y ,
'Ar tic I ed pup iI',
'Student ap prentice',
'G raduate a p prentice',
'Manag em ent tra inee',
'Trainee technician', or
'Trai nee craftsman'
as appropriate, (see note 818)
B19
How many hours
per week does
the person usually
w o r k in this job?
Exclude overtime
and meal breaks.
For all persons with a job last week.
For women aged under 60 who are married,
widowed or divorced.
For persons with more than one job these questions apply to the main employment last week.
ny hours
?k does
l n usuallb
this job ?
overtime
NIbreaks.
B20
What is the full address of the
person's place of work?
(see note 820)
If the work is carried on mainly
at home write 'AT H O ME'.
B21
What means of transpor1
does the person normally
use for the longest part, by
distance, of the daily journe
to w o r k ? (see note B U )
If the person walks to
work, or works mainly at
home, write ' N O N E'.
BLOCK CAPITALS PLEASE
822
B23
Was t h e person's
824
occupation one year
ago the same as last
a
week 1
Enter the month and year of birth
of each child born alive to her in
marriage ;include any who have
since died.
If so, write 'SAME'.
If none, write 'NONE'.
b If the first marriage has
ended (by the husband's
death or by divorce) write
the month and year w h e n it
ended. If n o t ended, write
'NOT ENDED'
If not, give details of
t h e occupation one year
ago. (see note B16)
If none. write 'NONE'.
Enter the dates in order of birth,
starting with the first born.
If she has been married more than
once give the dates for the
children of all her marriages.
Month
Year
av
Month
Year
Write t h e month and year
of marriage (the first
marriage if married more
than once).
a Date of (first) marriage
Month
Year
OFFICIAL
USE
HCA
GCE
................
................
QM
b Date (first) marriage ended
Month
Month
Year
Month
Year
Year
a Date of (first) marriage
Month
Year
...............
MIG 1...............
MIG 5
H CA
GCE
................
................
QM
b Date (first) marriage ended
Month
Month
Year
Month
Year
Year
a Date of (first) marriage
Month
Year
...............
MIG 1 ...............
MIG 5
................
GCE ................
HCA
QM
b Date (first) marriage ended
Month
Year
MIG 5
...............
...............
MIG 1
Month
Year
Month
Year
a Date of (first) marriage
Month
Year
b Date (first) marriage ended
Month
Month
Year
Month
Year
Year
a Date of (first) marriage
Month
Year
HCA
................
GCE
...............
...............
MIG 1 ...............
MIG 5
................
GCE 2.............
H CA
QM
b Date (first) marriage ended
Month
Month
Year
Month
Year
Year
a Date of (first) marriage
Month
Year
...............
MIG 1 ...............
MIG 5
HCA
GCE
b Date (first) marriage ended
Month
7
................
................
QM
Year
MIG 5
...............
MIG 1
...............
PLEASE TURN OVER TO PART*-C
whom, therefore, you have made no entry in Part B.
C
I
If no one is absent tick this box+
c1
a Write the name and
c2
Write the sex,
Questions C4-C7 need not be answered for absent p
c
-
*
c3
Write 'SI NG LE',
surname of every person
usually living in this
household .who is absent
on Census night.
(M for male, F for
'MARRIED',
female),
'WIDOWED' or
b Write relationship to
and date of birth of
'DIVORCED' as
the person.
appropriate.
the head of the household,
for example 'Head',
'Wife', 'Son',
'Daughter-in-law'.
If separated and
not divorced
write ' MAR R I ED
"s
c4
Did the person have a job last week (the
week ended 24th April 1971)?
(see note 87)
Tick b o x 1 if the person had a job even if it
w a s only part-time or if the person w a s
temporarily away from work, on holiday, sick.
on strike, o r laid off.
If the person did not have a job tick whichever
of boxes 2,3, 4 or 5 is appropriate : if box .5 is
ticked state the reason ; for example 'Housewife', 'Student', 'Permanently sick'.
'.
A
P
O
WI
CE
WI
bu
err
em
na
bu
(sc
Gi
on
1 st absent person
a
Name
Sex
4
NO
5
NO
2
b Relationship
0
- wholly retired
- not seeking w o r k for some other
a Name
1
Sex
YES - in a job at some time during
the week
NO - seeking w o r k or waiting to take
*up job
NO - intending to seek w o r k but sick
2
u
3
0
4
NO
5
NO
sex
1
2
3
4
....................................................
b Relationship
- wholly retired
- not seeking work for some other
6
a
Name'
....................................................
b Relationship
Sex
1
YES - in a job a t some tirne during
the w e e k
NO - seeking w o r k or waiting to take
up job
NO - intending to seek work but sick
- wholly retired
NO - not seeking w o r k for some other
NO
b
a
b
reason, namely
YES - in a job a t some time during
3
the week
NO - seeking w o r k or waiting to take
up job
NO intending to seek work but sick
4
NO
- wholly retired
5
NO
- not seeking w o r k for some other
2
a
reason, namely
......................................
4th absent person
b
reason, namely
......................................
3rd absent person
a
....................................... -
2 n d absent person
a Name
3
YES - in a j o b at some time during
the week
NO - seeking w o r k or waiting to take
up j o b
NO - intending to seek w o r k but sick
I
a
-
reason, namely
......................................
Important
If there is anybody that you have not listed in Pqrt B or Part C
because you were not sure whether he should be includedl'or because
you had no room on the form please ask the enumerator to help you.
a
b
this household but who is not present and for
ibsent persons under 15 years of age.
e
it
Answer questions C5-C7 in respect of the main employment last week, or of the most recent job if retired
or out of work. For persons who have never had a job and for a housewife who did not have a job last week, write ' N O N E'at C5.
S
\.
:r
S
c5
What was the name and
business of the person's
employer ( if selfemployed, the name and
nature of the person's
business) ?
(see note B15)
Give the trading name if
C6
What was the person's
occupation 1
c7
Was the person
an employee,
'or self-employed
employing others
(see note B17),
or self-employed
without employees ?
Give full details.
(see note B16)
one was used.
a Nameof
business
.e
k
er
1
An employee
2
pm
;eilSP
l;lgd:,
others
(see note B I 7
b Nature of
business
3
u
oyedl;:S
;$;
..
emdovees
a Named
business
e
1
An employee
1
An employee
k
ler
b Nature of
business
..
-
a
Nameof
business
e
k
ier
..
-
u
3
0s;e&w;loYed
b Nature of
business
Self-Fmployed,
employing
others
(see note 817
employees
a Nameof
business
1
.e
k
ier
2
0An employee
2
b
Self-emplo. ed,
employin g
k
others
(see note B l 7
Nature of
business
..
Declaration to be made by the head of the household or other person
making the return.
I declare that this form is correctly completed t o the best of my knowledge and
belief.
Signature
I
Date
......................................................
..........................................
J.S. O. 66-3856 11/70