Page 20

DAILY REMINDER LIST

PP Please review the list af expenses below with other members of your
household at the end of each day. If you have forgotten to record ony
expense, please do so on the appropriate page.

EXPENSES FOR:

a. Food and beverages purchased at a restaurant or carry-out (including
school junches and vending machine purchases)

. Snack foods (potato chips, pretzels, etc.)

. Beer, wine, whiskey, and other alcoholic beverages

. Cigarettes, tobacco, or other smoking supplies

. Lumber, nails, sandpaper, paint brushes, etc.

. Gasoline, turnpike or bridge tolls, parking fees, car pool expenses, et
. Newspapers, postage Stamps, greeting cards, etc.

. Vitamins, medicine, and other medical or sanitary supplies

. Laundry and dry cleaning (including coin-operated machines used at
a laundromat)

E

. Hair cuts and sets (including purchase and care of wigs and hair pifces~.

|

. Toys, hobbies, games, etc.

FORM CE-195 (4-11-72) ©GPO 1372.5 - 484-198



Page 14

SIXTH DAY Day
DAY
> Note: If you need additional space for any category, use pages 18 and 19,
FOOD AND BEVERAGES
Is this item -
Item Number Net weight (Mark only one) Total cost
OFFICE of tans, or z (Exclude
USE (Describe the item purchased, such as bottles, | volume per unit fet ot & soles 10x)
whole milk, T-bone steok, dried apricots, packages, (Exomples: sg! gie'g
ONLY ‘all purpose flour, saltines, ete.) etc Boz, 1a. 3{ oe! gle 1
: 5 Ibs., ete.) wy & O72 | pollars Cents
~ 56 010 | Dairy and Bakery Products (Indicate if milk is delivered) tot Hi
iT 12 Le} Icy T
A t 1 1 $ t
T2 T T T
8 "FP Po? ‘
72 T. T T
¢c oP i
TZ T Ti T
D Tze T
35 +t
E Trop (
Ese +
F 1 e Q H
G iY DP Ha H
ri Fo
J T ed Kd G
K re
Moat, Fish, and Poultry (Indicote the cut of meat) roto
L ; eB oF fs
m
N 12 3 4
oop
P HR Bo
| 1
Q | 1 ? 13 a
| _ Lt
T
R | i) e p is
s | 1 ig boom
| i
en
Tt eof ft
u vB
i —
Is
v 1 ig ia i
~ 56 028 | Fruits and Vegetables (indicate if dried) t t Hi
2 Tata
A oot
T, T T. t
B r op i H
c 7 pte Te ;
D i mo ¢ H
E PR (
F 2 8 a 1
G ig 2 3 (
H ~ t 42 8 14 j
4 ~~ ir 2 pa 1
{4 L
K Poe oe 1
Beverages H Hl H \
Te r
L L s \
‘ a T
1 ob n 1
N rome nm '
1 4
" ia -
1 4 1
r 2 3 T
Q 4 1 L t
it 12 ny 4 T
R : i—1—t r
~ 56 036 | All Other Foods a ee I
n 1 "2 Ey 1 3 H
co
3 Ta ae
T. T. T, T
c Tate T
3s T t
D ree t
2a t
1313
F i ta te H
13 —13—
S T 2 H
H roe Pp i !
: rz +3 ta 1
x 7243 fa 1
. nr 1
7 ee i
N Pee i
° ree #8 j
1
1 12 rE} 2 t
Q iL _, L
D \ 1 t
R poy 5
FORM CE-105 (4-11-72)



Page 5

FIRST DAY ar
ope
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE Item Was tats purchased at a - Total cost
' (Merk one)
onvy Unclude breakfasts, dinners, school lunches, 7 "5 7 7 {ncloce
snacks, and drinks purchased af o restaurant, . _ Drive-in tips
bar, vending machine, etc.) seers Restau | Cate: joe 1 Vending! other 4
~31 047 t icarcy-out | ) Dollars (Cents
T tz f) \
A _ 1 u ° i 1s $ t
2 i 12 "i 7 1S 1
— — +t. 4 J n J.
c 7 12 iE 1 15 1
— — | erates | 4; 1 7
12 y
D i 1 i i i i
ALL OTHER PURCHASES AND EXPENSES
T
| Toial cost Total cost
€
ose Hem 1 (Exclude ones Item (Exclude
ONLY (Describe the stem purchased) sales tox) ONLY (Describe the item purchased) soles tax)
| _Dotlars jCents Dollars }Cents|
1 1
Housewares, Furnishings, Hardware
Cleaning, Laundry Supplies \ " " , '
~ 21055 i ~ 21 089 | and Garden Suppties
and Paper Products t 8 (mirrors, light bulbs, nails, etc.) t
A $ 7 rai 5 |
8 t [el _| }
c i c mi
D i D TT
E i E }
F I F }
G i G i
7 Newspapers, Books, Postage, t |
Stationery, and School Suppiles { Tobacce ind Smoking Sapplles H
H 5 H ~ 5 i
J j J 1
kK : K ’
Personal Care, Drugs, and 1 Gas, Oll, Tolls, Parking Fees, ,
~ 21 063 |Medical Supplies y ~ 21 097 | and Other Vehicle Expenses; {
(Indicote if prescribed by 0 doctor) ' Public Transportation Expenses !
1 1
A ee s 4 $ :
y
8 I | \ n
c ' Cc i !
D T Clothing, Shoes, Jewelry, and Linens '
- (such as dress shirts, work shirts, ‘
E i casual slacks, etc.) i
\ yee,
F H o $ H
T
G _ _ Hl € | i
— T T
H ( F 1d
J i G i H
Laundry and Diaper Service, I Rent, Utilities, Fuel, Phone, Insurance T
Beauty and Barber Shop, I (Specify period covered by expense, H
Household Help, Babysitters i such as week, manth, yeor) —y I
K s i H I 3 ia
L H 3 r T
M i K i 1
N - i u i i 1
P ' Other Purchases and Expenses H
Q 1 (toys, hobbies, contributions, etc.) 1
R ! M s !
_| Movies, Plays, Other Entertainment, i N :
Club and Other Membership Dues 1 P t
: L L
' ’
s $s i Q
y Y
T L Ls |
u | H s \
GIFTS
Was this purchased,
OFFICE iter for a member oF Total cost
USE . this houselicld? (Exelude
ONLY (Describe the item purchosed) {Mark one) soles tox)
~ 3) 070 Yes {| No | Dollars jGents
A ' $ H A
B ' 2 i j
c ' e 1
Dy) ' iW ‘

FORM CE-105 (4-15-72)


Page 18

Use these pages for any purchases or expenses for which you did not
ADDITIONAL PAGE have enough space to enter on the appropriate day page. Enter che
day (Mon., Tue., etc.) tn the column headed ‘‘Day.’*
FOOD AND BEVERAGES
item Number Net weight om stn Total cost
OFFICE of cans, or PD TOT TS] (Exclude
ae ey ese es te pe re Sr odepicars, lpsccages,| ieeensiess | g, Bt Bt B| fale on
ONLY whole milk, . » packages, mples: Sree £1 3
all purpose flour, saltines, etc.) etc. 8 oz., } gt, 2; 2, 8, 8 T
5 ibs., ete.) Gi et GS! 2] potas \Cents
~ 68 015 Diary and Bakery Products it 3 Hl
r a PS
8 re Pp H
c j 1 2 a te H
5 | rR 7
: es
F Pp i
ot TE 7
f T 2 }
ni t 2 3 iB i
K a
Meat, Fish, and Poultry ' { ' }
L y 2 @ Ig f
Tu renee) 1
i cool
N a 2 13 14 H
3 EF
Q [ _f ees A
R Pee |
s Hl 1 2 13 4 |
T 1 Ha 1s 4 I
U 1 ia 8 u j
v Pee
~ 68 023 Fruits and Vegetables rot L
A reer
B i 2 i ‘a ¢ |
¢ re Pt i
D I ~ rT 72 "3 "3 Hl
E : r Ta '
F Hl 1 Ha 3 io H
¢ 7 Tea '
7 iz ‘
5 arcana '
” rete '
Beverages 1
L re ds 1
x TPP
M Te
12 1
; tess
4 n nN 1
RI Poet 1
~ 68 031 All Other Foods rot H
A Po es i
5 eo
¢ Po
° q 12 8 if H
= fz 3 H
F Por oe 1
CG q 12 B te i
4 ft 7
7 rte '
x! pes '
7 , Ta H
x T re ee i
x t TE a ;
P Te te a H
Q 1 i cy 1
R ee 1

FORM CE-105 (4-11-72)


Page 10

FOURTH DAY Day
Note: I‘ you need additional space fox any category, use pages 18 and 19,
FOOD AND BEVERAGES
Item Number Net weight (sis item = Total cost
OFFICE of cans, ot TT TB (Exclude
USE (Describe the item purchased, such os bottles, | volume per unit Yoel gt &) sales tox)
ONLY whole mitk, jibone steak, dried epricets, packages, (Examples: s H 3 ! 2 : =
al! purpose flour, saltines, etc ele. Boz, I qt, 2; 8! §) g+}——_—+
5 tbs., ete.) ey) oO; © | potlars 1 Cents
~ 54.015 | Daity and Bakery Products (Indicote if milk is delivered)| To i
A PoP ds i
3 TF PF
c poe r
° a es
5 a a
: Po
5 Te?
H O id p Hd 1
J 1 ia o Hy Y
K PC i
Meat, Fish, and Poultry (Indicote the cut of meat) - totg a
L ee es 1
i ees
N fy? 13 a ' _|
P ae
Q Hf u i ‘« t
" fi Ba i
$ | ? 2 t H
Y : Pe oe TY]
u t ig 13 i | |
Vv ee ~
~ 54.023 | Frutts and Vegetables (indicate if cried) 1 ot 4 1
; ae
B TRS *
C 2 B io H
D ERE
E fe se '
r 7 2 eT H
C yee ta F
< ah
" a
K Poe oe |
Beverages H i! | H
L PPE
M o 12 1B e TI
1 1 1
N q 2 8 T
P Fe 8 T
Q 4 o 12 8 TY
R ay T
~ 54031 | all Other Foods” To. Hl
A ff Pp ffs t
3 Tae H
¢ Tk ——
5 FPF
pe '
F 1 2 ts Te {
C 1 ee) i
H opp 1
5 a 4
, ee ;
L Tf 4348
M Tes 8 t
corer
' ’ I 1
f aa t
; at
4 1 tL 1

FORM CE-SO8 (4-11-72)


Page?

SECOND DAY Lire.
LuPc
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE f Was this purchased ata — Total cost
USE tem (Mark one) :
ONLY (include breakfasts, dinners, school lunches, T 7 7 7 Moclude
savete, gg inks murchesed ore estouren!, | Resraw | cate PGE ‘vending! yy |__ “ee
~ 32.045 tant i teria [catty-out f machine Dollars Kents
’ 1 ( 1
pp ft
: 1
8 1 1 1 n 1
i 12 IF 1% 15 1
c 1 1 4 1 1
D 1 12 3 ry 15 1
1 1 4 1 1
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
ICE
one Item (Exclude | OFFICE Item [Exclude
ONLY (Describe the item purchased) soles tox) onty (Describe the item purchosed) sales tox)
Dollars |Cents Dollars _)Cents|
1 F 1
Housewares, Furnishings, Hardware,
Cleaning, Laundry Supplies, 1 p y '
~ 22053 D ~ 22 087 | and Garden Supplies
and Pape Products I (mirrors, light bulbs, nails, etc.) I
T T
A _ $ Hl A $ }
7 T
B I B 1
c rife i
D ' D i
E i E T
F i F i
G i G '
Newspapers, Books, Postage, ! !
Statlonery, and School Supplies ! Tobacco and Smoking Supplies !
H $ a H $ t
J 1 J
= a Sa ae
K ! K 1
Personal Cara, Drugs, and Gas, OI, Tolls, Parking Fees, 1
~ 22.061 | Medical Suppties — ~ 22.095 | and Other Vehicle Expenses; !
Undicete if prescribed by a doctor) Pubtle Transportation Expenses '
1
A $ 5 '
1
8 4
c c i
D Clothing, Shoes, Jewelry, and Linens t
{such as dress shirts, work shirts, '
E casual slacks, etc.)
T
r _ D $ i
T
G E Hl
H F H
J 6 1
Laundry and Diaper Service, Rent, Utilitles, Fuel, Phone, Insurance Hl
Beauty and Barber Shop, (Specify period covered by expense, H
Household Help, Babysitters such os week, month, year) —y t
K $ H : H
L 1 ) } 1
M _ K | i
N ‘ L Hl ‘
P ! Other Purchases and Expenses '
Q 1 (toys, hobbies, contributions, etc.) 1
R 1 ivy s |
Movies; Plays, Other Entertainment; : N H
Club and Other Membership Dues i P (
1 \
‘
$ i {8 1
1 ’
T i R H
u \ s 1
GIFTS
Was this purchased}
OFFICE item for a member of Total cost
USE this household? (Exclude
ONLY (Describe the item purchased) (Mark one} sales tax)
~ 32 078 Yes ; No | Dollars jCents
A 1 2 $ i
B y 2 i
¢ y 2 i
D ' 2 H
\ 1

FORM CE-105 (4-11-72!


Page 6

SECOND DAY bays
DAY
Note: If you need additional space for any category, use pages 18 and }9.
FOOD AND BEVERAGES
sai Is this em -
lten Nuniter Net weight (Mack only one) Total cost
OFFICE of cans, ol fT t—? S]  ¢Exctude
USE (Describe the item purchased, such as bottles, | volume per unit beet el Bl oes ton
whole milk, T-bone steak, dried apricots, packages (Exomples. sit etgts
ONLY all purpose flour, saltines, etc.) te Bez, gt, 3) st gig 1
: § Ibs., etc.) wait 8: © | dollars Cents
~ 52019 | dairy and Bakery Products (Indicate if milk is delivered) Ty 4 H
A _ 1 T TZ $ T
rot U
B r
a
c —— ves T
root
= T. T 7.
D Fr Ps i
E T Kg T3 Te =o H
vo
F : ee
g FPF
i a a a
A ~] Y Prop H
. 7 ce eae +
Meat, Fish, and Poultry (Indicate the cut of meot) too 1 !
L V2 12 4 ‘5 !
M ie Be (
T 1 12 13 4a Hl
N 1 Pop 1
| (a8 j
a " Pe 8 ~ “ '
R Fee 1
s 7 Te 8 T
- 4
T 1 2 ‘3 14 t
~ L
u rte T
L
Vv re & hs r
‘
~ 52.027 | Frults and Vegetables (Indicate if dried) H i i i
A . ro? Pp ffs i
i
B - ror PF i
c roe Pp {
D |? eB F i
E ~ roe 1
F rR te
- L
G roe 1
—_ ——|.
4 a na) V
¢ L
j Tae j
as _ 1
K rz ea 1
a L
Beverages : i am i i
L _ Fee fg
rz a a
nm 44 f
Tr 412)~O ao 7 tT
N Lo $
P ye 8 a t
= n 1
Q Tz i
1 1 1
R . 12 [Ey ir) H
a
~ 52 035 | All Other Foods T T ! T
a] f :
A | i
t T
c 1
Dy}
E ~
F
G —
[HI
J _ —_
K
L
M
N
P
Q |
T
R i
FORM CE-108 (4-11-72)


Page (9

ADDITIONAL PAGE

MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.

Was this purchased at -
OFFICE Item (Mork one) Total cost
USE Day | (include breakfasts, dinners, school lunches, 7 7 ; 7 (Include
ONLY gnocks, and drinks purchased at o restouront, | pastay.! Cate 1° | Venuing! oy, tips)
jor, vending mochine, etc. rant | teria! ‘machine! er
~ 48 041 ! { carry-out! ! Dotlars | Gents
A 1 12 rE 1a 1s 7 H
1 1 1 i ‘
B 1 RR 13 ry 15. 1
t ‘ 1 n 1
Cc 1 2 ‘3 ‘a Is 1
1 \
p EC
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
one Day Item (Exclude wee day Item (Exclude
ONLY (Describe the item purchased) |_S0/es tox) ONLY ‘Describe the item purchased) soles tox)
Dollars !Cents Dollars | Cents!
Housewares, Furnlshings, Hard - 1
Cleaning, Laundry Supplies, 4 ware, and Gard a 1
~ ~ , jen Supplies
38 059 and Paper Products \ 38 083 (micrors, light bulbs, nails, etc,) '
A s ft A 3 !
B ! B '
C ! c i
o ' o I
E : E i
F 1 F
s _|¢
dew: i i
Newspapers, Books, Postage,
Stationery, and School Supplies \ Tobacco and Smoking Supplies ;
T T
Hq $ \ H $ \
[ i |s 1
K i i K 1
H Gas, Oll, Tolls, Parking Fé if
~38 067 Grid atl ee | |~38 091 and Other Vehicle Expenses; f
¢ 1 Public Transportation Expenses. |
A ' $ i A $ '
B t B 1
| f
1
¢c |! [ec f
. ; 1 Clothing, Shoes, Jewelry, and 1
+ Linens (such as dress shirts, {
E | ' work shirts, casuat slacks, etc.) H
F { > s H
6 \ E H
H ‘ Fe i
t |
J H G i
Laundry and Dlaper Service, T Rent, Utilltles, Fuel, Phone i
Beauty and Barber Shop, { Insurance (Specify period ’ \
Household Help, ‘Babysitters i covered oy etmcity es {
K 5 T week, month, year) —y H
L i 4 : a $ 1 |
M H J 1 Hl
N ' K i H
P H Other Purchases and i
T Expenses (toys, hobbies, t
Q . 1 contributions, etc.) !
R 1 M $s nl
Movies, Plays, Other H N 1
Entertainment, Club and H - L
Other Membership Dues 1 P fl
$ $s ! Q H
T ! Ri H
U H s] H
GIFTS
Was this purchased
OFFICE ‘ten for a member of Total cost
USE Da this household? (Exclude
ONLY yo (Describe the item purchased) (Mark one) soles tax)
~48 074 Yes 1 No | Dollars iGents
A 1 12 5 1
B 1 12 1
c v 12 1
Hi 1 1
id ‘a 1



Page 9

THIRD DAY circ.
cpec
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE Item Was this purchased ala Total cost
rk one,
USE (include breokfasts, dinners, schoo! lunches, i oo 7 } (clude
ONLY snacks, and drinks purchased at a restaurant, 1 _ | Drive-in | tips)
; Restau- | Cate Vending |
bar, vending machine, etc.) ase Ca or renee, Other
~ 33 043 t [earor-out t ! Dollars {Cents}
' i} \ ‘
A oes
' 1 rr 1
8 1 f 1 H 1
7 12 iF) 4 3 Y
c I i | i 1
1 13 is 3
© ‘ ie L 1 t 1
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
one tem (Exclude | OFFICE Item (Exclude
ONLY (Describe the item purchased) sales tax) ONLY (Describe the item purchosed) soles tox)
Dollars {Cents Dollars {Cents|
1 1
Housewares, Furnishings, Hardware
Cleaning, Laundry Suppites \ p 7 " 1
~ 2305) , ~ 23 085 | and Garden Supplies
and Paper Products H (mirrors, light bulbs, nails, ete.) |
al § i A $ H
T T
ae ee Hl 8 H
G t c i
D 1 D an
E oe
F i F '
G ' G I
Newspapers, Books, Postage, i 7 '
Statlonery, and Schoal Suppiles | Tobacco and Smoking Supplies H
H $ i H $ 1
3
K 1 K 1
Personal Care, Drugs, and t Gas, Oll, Tolls, Parking Fi i
~ 23.069 | Medical Supplies ! ~ 23 093 | and Other Vehicle Expanse: !
(indicate if prescribed by 0 doctor) H Public Transportation Expenses H
t 1
A A ! $ f
1 t
8 n n
1 t
c ‘ i
D T Clothing, Shoes, Jewelry, and Linens T
- (such as dress shirts, work shirts, !
E 1 casual slacks, etc.) H
F T [o s H
G i E i
~ T
H LF 1
14
J i G i
Laundry and Dfaper Service, 7 Rent, Utilities, Fuel, Phone, Insurance i
Beauly and Barber Shop, i (Specify period covered by expense, 1
Household Help, Babysitters 1 such os week, month, yeor) —y t
K $ ' H j s i
L 1 J j ‘
M i K q i
N t L Hl t
P : Other Purchases and Expenses H
Q i (toys, hobbies, contributions, etc.) 1
R ‘ M $ H
Movies, Plays, Othar Entertainment, H N H
Club and Other Membership Ques ' P (
L ‘
1
$ L Q \
T | oe . 1
,
u i $ L
GIFTS
Was this purchased
OFFICE item for a member of Total cost
USE this household? (Exclude
ONLY (Describe the item purchosed) (Mark one) soles tox)
~ 33 076 Yes ; No | Dollars Cents
A ' a $ i f
B 1 z i
t 7 ig H
7 2
> i i

FORM CE-408 (4-11-72)


O.M.B. No. 41-S72032; Aoproval Expires December 31, 1974

Form CE-105
(ar 4-72)

U.S. DEPARTMENT OF COMMERCE
SOCIAL AND ECONOMIC STATISTICS AOMINISTRATION
BUREAU OF THE CENSUS

ACTING AS COLLECTING AGENT FOR

U.S. DEPARTMENT OF LABOR
BUREAU OF LABOR STATISTICS

RECORD OF YOUR DAILY EXPENSES

For the Period

Day Date

| FROM

THROUGH

NOTICE — All information which would permit identification of the
individual wil! be held in strict confidence, will be used only by persons
engaged in and for the purpases of the survey, and will not be disclosed
or released to others for any purposes.

~91 017 OFFICE USE ONLY PROCESSING USE ONLY
1. Control number 2. HH No, |3. CUNo.|4. Diary [5. Starting /6. Additional |7.
PSU Sample | Serial ‘ck Dig! 1 day units

i}
L L i

‘
\ 1 : 2
‘ :



Page 12

FIFTH DAY bay
DAY
Note: If you need additional space for any category, use pages 1 and 19.
FOOD AND BEVERAGES
Number el wei Is this cam —
orrice hem done N \ weight (Mork only one) Total cost
USE (Describe the item purchosed, such os boltles, | volume per unit ! < Tot z (Exclude
Y whole milk, T-bone steak, dried apricots, | packages, (Examples: =! Si Bi B]  seles tox)
ONL all purpose flour, saltines, etc.) ee goz., qh, gigi gig ;
: S lbs. etc.) Sry oy ©! polists iCents
~ 55.012 | Dairy and Bakery Products (Indicate if milk is delivered) od H
1 7 LEY Ta |
A ' ‘ 1 $ I
1 2 3 ary T
B t i { i 1
T2 T ars
¢ re i
ry T. T
D fr PF i
E 1 “TZ Ty TM
1 I t 1
1 —
F 3s H
G se 4
H f Hd De Ho 1
J j O 2 3B i 1
x T2348 ;
!
Meat, Fish, and Poultry (Indicote the cut of meat) | ' ’ ‘
H ‘
L TF Is
Me 1 12 3 a 1
n f
N ul 12 3 14 if
H 4 H
Pp 1 12 03 4a i
po 1
Q roa sa 1
-. J n 1 i
R Tar) 1
oy :
s yo la is a v
1 — 4 !
T fl 2 43 4 ‘
—
U rR 8 H
v 1 esta T
1 1 1 1
~ 55.020 | Fruits and Vegetables (Indicote if dried) {14 Hl
A o 2 ta l4 r
' ‘ i)
aT :
B ' *F of '
c FR Pi i
D (ore +
E roo 1
F DCC) 1
!
c ya ete 7
A 1
H , 2 3 I
: a
1 \
K re 3 T
: 4 f
Beverages 1 nl 1 t
| 1
tL La
M 2 3 T
41 1
N U 12 3 ry T
—. se 1 1 1 !
P er T
aI 1 1 1
Q 0 ° 13 ry T
{ i
R 0 12 13, 1a T
1 1 4 !
~ 55.038 | alt Other Foods TT T
I -——
[A | Te at 7
7 -
B ‘ ia u
' :
c 1 ? 1
D ee i
E _ hi? 5 1
F _ 0 my T
S ye '
K a2 H
h
5 T4243
!
K " 2 p a 1
H
L 42 3 y
x 1 2 43. 6 n
i H i
N T1243 1
rin 1
P 23 '
4 re 1 4
Q iY Wz rey ro 1
Lo ‘
R [' 2 B 4 1
1 1 1 4

FORM CEOS (4-11-72)


Page iI

FOURTH DAY oro
cc
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE ter Was this purchased at a — Total cost
USE (Mork one}
{include breakfasts, dinners, school lunches, 7 T T 7 (Include
ONLY gnacks, and drinks purchased of 0 restouron’, Restav- | Cafe. | DMYE" | Vending! tips)
1 vending machine, etc.) fone | Gores | pacing | Other
~ 34041 ! learry-out | \ Dallars ‘Cents
H 1 1
7 — hog fh 4+
y
8 L 1 i A L
’ 12 12 ry 3 '
Cc L i i H 4
D 1 wD 13 ny 15 ,
1 f 1 " nm
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
orrce Item (Exclude } OFFICE tem (Exclude
ONLY (Describe the item purchased) soles tox) onuy (Desceibe the item purchased) sales tex)
Dollars \Cents| Collars [Cenis|
! '
Housewares, Furnishings, Hardware
Cleaning, Laundry Supplies, : z " : H
~ 24059 ~ 24 083 | and Garden Supplies
and Paper Products ' imirrors, light bulbs, naifs, etc.) H
~ T
A s j A $ i
T
B i B _ H _|
G t g (
o i D i
7 7
E \ E i
T T
F ‘ F 1
G i G {
Newspapers, Books, Poslage, ! i
Stalfonery, and School Supplies : Tobacco and Smoking Supplies 1
H $ ‘ H $ '
3 ‘ J i
K \ K i
Personal Care, Drugs, and 1 Gas, Oil, Tolls, Parking Fees, i
~ 24 067 |Medicat Supplies | ~ 24 091 | and Other Vehicle Expenses; !
(Incdicote if prescribed by.o doctor) ! Public Transportation Expenses i
i)
A s 4 $ H
B t \
1
c ( |
D T Clathing, Shoes, Jewelry, and Linens T
t (such as dress shirts, work shirts, '
£ i casual slacks, etc.) H
F i D $ I
G H E T
H H F T
J i s H
Laundry and Dlapey Service, H Rent, Utilities, Fuel, Phone, Insurance '
Beauty and Barber Shon, 1 (Specify period covered by expense, 7 4
Household Help, Babysitters 1 such as week, month, year) —y '
K s i H ! 3 i
L 1 J H i
t
M { K { i
N ' t i
rs i i
Other Purchases and Expenses 1
Q 1 (toys, hobbies, contributions, etc.) 1
R , 1 rm $ !
Movies, Plays, Othar Entertainment, { N {
Club and Other Membership Dues 1 P 1
A 1
s i 4a H
1
R
U t s
GIFTS
Was this purchased
OFFICE len for a member of Tota, cost
USE this household? (Exclude
ONLY (Describe the item purchosed) (Mark one) soles tox)
~ 34 074 Yes | No | Dollars {Cents
eS A
B ' 2 {
c v 2 i
i} ' 2 (
1 H

FORM CE-108 (4-11-72)


Page 8

THIRD DAY bay
Note: If you need additional space for any category, use pages 18 and 19.
FOOD AND BEVERAGES

item Number Nel weight (hotest ney Total cost

OFFICE i of cans, - B) (Exclude

USE (Describe the item purchased, such as bottles, | volume per unit 1 el gt S| gates tox)

ONLY whole milk, T-bone steak, dried ooricots, | packages, | (Exorpes: gi gibi?
off purpose flour, saftines, ete. Boz, 1 qt, $) 2) §| 8 ——-—
$ tbs., etc-) wy oO; | doliars_i Cents
~ 53.017 | Dairy and Bakery Products (Indicate if milk is delivered) | +4 H
A a
8 root H
c ros
D r P r H
E . td Hid r H
F mg p r !
o mF
H roy 1
J vo i
K mop if i
Meat, Fish, and Poultry (indicate the cut of meat) oat j
L ig Dp 3 1
m - zoe
N oo ft |
P yo |
Q a Be i
R zoe
3 eps H
T _ i as T
uU _ 2 3 Va H
Vv aM H
~ 53.025 | Felts and Vegetables (Indicate if dried) i ot H
A eo fs i
8 Ts Wa H
c es Ta '
° ro if i
E : man
F a mz t
G ts Ta
H f
1 eee f
is !
Beverages i
L s t
M ft [ t
N _ _ 4
p Hi
Q _ I
R f
~ 53.033 | All other Foods T
A s 1
6
¢ t
D

E 1
[r | i
G i}
i .
J _ t
K . H
L !
M L
N H
P \
c] \
R i

FORM CE-108 (a-f1-72)



Page 4

FIRST DAY bay
DAY
Note: If you need additional space for any category, use pages 18 and 19,
FOOD AND BEVERAGES
: Number et weight Is this item -
orrice ‘tem | Sfeane N we | (Mork only one} Total cost
, an on io
USE (Describe the item purchased, such as bottles, | volume per unit ret gt & LExclude
ony whole milk, T-bene steak, dried opricots, | packages (Exomples: e! Bi Br By sates tox)
L oll purpose flour, saltines, etc.) ec Boz, ) gt, gs! St gle 1
§ Ibs., etc.) ey) 87 % | pollars ICents
~ 51011 | Dairy and Bakery Products (indicate if milk is delivered) 1 td Hi
it 2 LEY 14 T
A vor fs i
B T 1 2 13 T
' ( i (
17131
¢ Por oe i
1713
° oF eo {
E T1315 t
= I I 1 1
<1 t
F 0 Ha ° Ky H
G 1 Ce Pr r H
H TY Re 1
J ro pe H
K + a2 3 14 i
- !
Mest, Fish, and Poultry (Indicate the cut of meat) yo 1
L Fg :
M 7 2 ee 1
i 4
N 1 12 Ba 14 1
Pop | 4
Pp yea i
i N 1 1
Q " 2 13 14 t
i H
R rr 7
oo —|
s v2 A —
1 a
T 1 (2 ta ia T
1 1 1 1
u to 12 13a T
I i L 1
v 2 te T
1 i I
~ 51029 | Fruits and Vagetables (indicate if dried) Toto T
5
A Por oe ds i
B i ma T Tq , _
! t !
c | oF eo i
t ayo
1°) ; " i e ’
E ro? 8 ‘
> a —
6 re 8 r
1H ~ ye ata t
: i
7 ie at 1
tt i
K 28 1
QE f
Beverages H ‘ ' t
2 a ry 7
L 7 124
1 i $ fl
M tT 12 8 T
- ieee ee \
N r2. B # T
J 1 1 {
P Tes a T
. st ‘
Q 1 12 B 4 T
— 1 1 L '
R Tee Tv
t Ls
~ T T r
54 037 | All Other Foods ot { i
' t
rn 72 a H
3 1 Te t
| T2 T t T
c . | so? Po \
1p t
D rf ae ’ 1
E oP 8 i
F TR a H
6 ye te H
a he tse t
y 7 2p uy T
= H
x Te e t
H
L 1 2 43 1
H
M 2 3 18 1
! na i
N tT 2 3 - n
41 t L
P Ta? @  ¢ Y
—t 4 1 A
Q T 2 3 t
bot 1
R 2 rey ry 1
FORM CE-105 (4-11-72) ;



Page 15

SIXTH DAY Spc.
mpc
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE Item Was this purchased at a — Total cost
(Marx one)
ony (include breakfasts, dinners, school lunches, ro 1 Di T 7 (inclode
snacks, ond drinks purchased of a restaurant, at _ 7 Drive-in ; i tips
bar, vending machine, etc.) Restau- | Cafes | or vending | other
~ 46 046 ! ‘earry-out ! ! Doliars iCents
f) A 4, '
4 +4
B L f f I 1
1 12 13 4 1 1
5 + —t}—*
1
G a a
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
ote Item (Exclude ives Item (Exclude
ONLY (Describe the item purchased) soles tox) onLy (Describe the item purchosed) soles tox)
Oollars [Cents Doilars {Cents
1 1
Housewares, Furnishings, Hardware,
Cleaning, Laundry Supplies, 1 and Garden bu ' 1
~ : ~ ippties
26 054 | and Paper Products 26 088 | rvcrors, tight tulbs, nails, etc.) I
A $ H A 5 Hl
8 i__|[e H
ci i_fe i
D i D i
E i E 1
T Tr
F f F t
G i G ‘
Newspapers, Books, Postage, H
Stationery, and Schoo! Supplies ui Tobacco and Smoking Suppiles \
H s i H $ H
J 1 a i
‘ K - 1
Personal Care, Drugs, and 1 Gas, Oll, Tolls, Parking Fees, !
~ 26 062 | Medical Suppiles ! ~ 26 096 | and Other Vehicle Expenses; '
(Indicate if prescribed by a doctor) ! Pualic Transportation Expenses !
‘ i)
A $ 5 1
1
B 1 8 __ L
Y
c 1 i
D TT Clothing, Shoes, Jewelry, and Linens r
+ (such as dress shirts, work shirts, '
E \ casual slacks, etc.) j
F f s
6 i E f
4 ie Hi
J 1 Is] i
Laundry and Diaper Service, ‘ Rent, Utlilties, Fuel, Phane, Insurance Hl
Beauty and Barber Shop, H (Specify period coverad by expense, '
Household Help, Babysitters 1 such os week, month, yeor) 1
~~)
K "s i H j $ i
L i J ' Hl
M 1 K t 1
N \ L Hl I
P H Other Purchases and Expenses H
Q 1 (toys, hobbies, contributions, etc.) 1
R 1 M 3 j
Movies, Plays, Other Entertainment, H N t
Club and Other Membership Dues 1 P 1
L 1
1
$ H Q 1
1
T 1 R 1
u j s Ll
GIFTS
Was this purchased|
OFFICE it ofa his purchased] Total cost
USE en this household? /Exelude
ONLY (Describe the item purchased) {Mark ove) sales tox)
~ 36 079 Yes 1 No | Dollars Cents
A ‘ a $ T
8 ¢ ig Hl
c 1 2 H
D ¥ 2 t
t

FORM CE-108 (4-11-72)


Page |7

SEVENTH DAY ore.
cee
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE Item Was this purchased at a — Total cost
(Mork
USE (Include breoklosts, dinners, school lunches, 7 (Merk ene) (include
ONLY snacks, ond drinks purchased of a restaurant, Restaue! Cafe. | Drive-in 1 Vending t tips)
bar, vending machine, etc.) rant} teria 140 yt machine? Other
~ 37 044 H [carry-out f ' Dollars {Cents
A 1 2 G t 15 s !
H
7 iz 1s ro Es 1
B iF 5 t H tL
1 1 1 4 is 1
c 1 tL 1 1 1
D ! Ha i i fi t
ALL OTHER PURCHASES AND EXPENSES
Totai cost Total cost
OFFICE Q
oe Item (Exclude one Item (Exclude
ONLY (Describe the item purchosed) soles tox) ONLY (Describe the stem purchosed) sales tox)
Dollars jCents Dollars Cents
t Furnishings, Hardware, '
Cleaning, Laundry Supplies, 1 Housewares, Bs, " n
~ 27 052 ~ an Garden Supplies
and Paper Products i ! 27 086 | (rirrors, light bulbs, nails, etc.) |
7 T
A 5 ' A s |
T
8 1 |e 1
¢ rie i
0 i D I
E T— +
: r
F ! F i
G i S| t
Newspapers, Books, Postage, f '
Stationery, and School Supplies f Tabacco and Smoking Supplies H
H $ i H $ i
J 1 J 1
x ! K i
27 060 Hredteat Supplies mae H 27 094 rT ‘one Veae Cane Fees, t
~ u i ~ r xpanses;
(lodicate if prescribed by a doctor) f Public Transportation Expenses i
1
A $ ‘ $ H
8 ! 8 !
c i c !
D T Clothing, Shoes, Jowalry, and Linens i)
: (such as dress shirts, work shirts, '
E H casual slacks, etc.) t
i
F i D $ t
CG H E |
T
4 T F T
J H 6 H
Laundry and Diaper Service, i Rent, Util Fuel, Phone, Insurance H
Beauty and Barber Shop, H (Specify period covered by expense, I.
Housshold Help, Babysitters 1 such os week, month, year) — i
K $ i H fl $ i
L \ J i i
M i K I 1
N 1 [u ; t |
P i Other Purchases and Expenses \
@ 1 (toys, hobbies, contributions, etc.) {
R f x 5 i
Movies, Plays, Other Entertainment, | N H
Club and Other Membership: Dues 1 P !
4 n
s 1 |@ I
1
L R 1
ts
GIFTS
Was this purchased
one Item for a member of Total cost
USE this household? (Exclude
ONLY (Describe the item purchased) (Mark one) soles tox)
~ 37 077 Yes { No | Dollars jCents
A ’ a $ 1 A
B ' 12 1
c ' 2 1
D 1 (2 4
1 L

FORM CE-108 (4-11-72)


PP Pleose provide the following information when recording these items:

Page 3

FOOD AND BEVERAGES

Milk — Specify if whole, skim, half and half, chocolate, condensed, etc.

Cheese — Specify if solid cheese, cheese spread, or cheese dip.

Bread — Specify if white, whole-wheat, rye, pumpernickel, etc.

Beef — Specify the cut and describe, such as round steak, sirloin steak, ground beef, prime ribs, etc.
Pork — Specify the cut and describe, such as loin roast, fresh whole ham, spareribs, bacon, etc,
Chicken — Specify if fryer, broiler, parts (sold separately) or other chicken.

Soft Drinks — Specify if cola or other type. If not cola, specify if carbonated or noncarbonated.
Coffee — Specify if instant or ground; if ground, indicate if in bags or cans.

Tea — Specify if instant, tea bags, or loose.

Sugor — Specify if white, brown, granulated, confectioners’, or powdered.

Cereal — Specify type (corn flakes) or brand name.

Flour — Specify if white. all purpose, cake, whole-wheat or other flour.

DETERGENTS — Specify if for laundry, household cleaning, or dishwasher and if liquid or powder.
DOCTOR BILLS ~ Specify type of doctor visited, such as general practitioner, internist, etc.
DENTIST BILLS — Specify the type of work, such as extractions, teeth straightening, etc.

TOYS — Specify, such as games, electric train set, doll, etc.

> EXAMPLES OF SOME FOOD ITEMS

FOOD AND BEVERAGES

T

Item Number Net weight pattie en : Total cost
of cans, or = T 1
once (Describe the item purchosed, such as bottles, | volume per unit Pet gis {Exclude
u whole milk, T-bane steok, dried opricots, | packages. (Examples: ec gigig
ONLY all purpose flour, soltines, etc.) elc Boz, qt, 8) 21 8, 8 7
7 5 tbs. esc.) wir ¢ C1 © | Dotlars_iCents
~ 50013 | dairy and Bakory Products (Indicore Hf milk is delivered) I ott i
. T T T
Ay Pytkh - 2% Z Bg |rr 7" ds | $3
T t T2 LEY ry
a Cottngs Aree {oy be.| x1 1 i Nos
~ 7 2 1. 2 TS Te T
c age Lhe. xt 157
5 i To i H
Meat, Fish, and Poultry (Indicote the cut of meat} roto j
L Beug pst Norst 7 aéestelx !? 8 1 Is 2ise
M Chichen parte Z 13946 |! Exe 187
N Pork ckape S6LE'X 7? BO wad
2 1 2 1 18 1
~ 50 021 | Fruits and Vegetables (Indicate if dried) rot i
+14
A foenack 2 fo. | exe it Is ‘58
~ A ~ —T mry T,
6 Miaurbenriee L Deets |x? Pf 124
Z 7 nn aS H
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE Item Was this purchased ata - Total cost
USE (include breakfosts, dinners, schoo! lunches, 7 7 7 7 (Inclode
ONLY snocks, and drinks purchased of @ restaurant, Restav- | Cate. (OME : Venging | ips
bar, vending machine, ete.) esau, Gales vending Other |__|
~ 30 049 H fearry-out | ! Dollars Cents
A Lurk tx eB i is 8/137
8 C ofgse- ee a WE
c a ached b Z 7 Py 3 ‘ 5 ‘90
nn 1 12 13 4 1s 1
> EXAMPLES OF SOME OTHER DAILY ENTRIES
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
one Item (Exclude oer Mem (Exclude
ONLY (Describe the item purchosed) | _soles tox) } OR (Deseribe the stem purchosed) | _S21es 10x)
Dotlars | Cents| Dollars jCents|
' Housewares, Furnishings, Hardware, A
7 Cleaning, Laundry Supplies, ! ~ and Garden Supplies H
20 057 | and Paper Products i 20 081 | trios light bulbs, nails, etc.) H
T
A Way paper s 129 [At Wastebathse 3 | oP
: t 1
gi Higa, laserclry birgal 149 |B Zight Color 1 £2
cl Hi et
Heeigpaal Cote, Drugs, and ! Gas, Oll, Tolls, Parking Fees,
w ledical ipplies ~ and Other Vehicle Ex, iS;
20 065 | (indicate if prescribed by 0 doctor) f 20099 | evbtte ‘Transportation Expenses !
Aa pirine s weal Maarten 8 196
B ALlensy BAe L5_ 12018 Bw LYS.
¢ y (



Page 2

INSTRUCTIONS

D> GENERAL INFORMATION

This form ts for recording ALL your expenses for a 7-day period. Beginning on page 4 there are two facing
pages for each day. Record each day's expenses on the appropriate pages. Enter the day in the heading as
shown below:

FIRSTDAY —[ENF® acs olay

p> WHAT TO REPORT

Record ALL purchases and other expenses of the persons shown in the box below during the period
indicated on the cover.

Include purchases ond expenses of - [_] ALL members of this househcld

CAI of the foltowing persons —

Include -Every purchase or expense, no matter how small or inexpensive it is.
The FULL cost of gasoline, clothing, and other icems purchased on credit during the period.
Costs for all snacks, beverages, and meals purchased at restaurants, carry-outs, etc,
Expenses for such things as entertainment, public transportation, babysitters, and contributions.
ALL bills PAID during the period for recurring expenses such as rent, mortgage, and insurance.

Do not include - The expenses of persons white they were away from home overnight.
Credit or installment plan PAYMENTS.
Purchases made entirely for business purposes.
Sales tax in the cost of the item.

> HOW TO REPORT

For some food items, certain information in the description of the item is needed in order to select the appropriate
item to price in the stores. These items and the information needed are listed on the opposite page. —————>
Please refer to the list when recording any of these items.

Also shown on the opposite page are a few examples of recorded expenses, It will be helpful to look at
these examples before recording your expenses,

D> WHERE TO RECORD EXPENSES

Enter all purchases and other expenses in the correct category on the page for the appropriate day. Record
gifts purchased in the ‘“‘gift’’ section. Two pages are provided for each day’s expenses.

If there is not enough space to record all expenses of a particular day on the lines provided, enter the
additional items on pages 18 and |9. BE SURE to specify the day on which the expenses occurred in the
column headed ‘Day.””

{f you do not know where to enter a food item, enter it in the “‘All Other Foods"’ category.

If you cannot determine where to enter any other item, enter it in the ‘‘Other Purchases and Expenses" category.

p> BEST TIME TO RECORD

Most people find that keeping the diary is easiest if they RECORD THEIR PURCHASES AS SOON AS THEY
GET HOME FROM THE STORE.

For recurring expenses such as rent, mortgage payments, utility bills, and other bills such as for doctor,
hospital, or dental services, record the amount of the expense on the day the bill is paid.

Each day the diary keeper should check with other household members for their expenditures during that day.
Also check the Daily Reminder List on the back cover for any expenses ycu may have forgotten to record.

p> ANY QUESTIONS?

| will be back on to pick up your completed diary. If you have any questions ia
the meantime, please calf me.

nterviewer's name Telephone — Areo code ond number

FORM CE-108 (4-51-72)


Page 13

FIFTH DAY Spe
cpec
MEALS AND SNACKS PURCHASED AT A RESTAURANT, CARRY-OUT, ETC.
OFFICE Ik Was this purchased at 4 — Total cost
USE em (Mark one}
Unclude breokfasts, dinners, school lunches, 7 T 7 7 Unclude
ONLY snocks, ond drinks purchased a! a restaurant, Restau-! Cafe. DYE" | Yenging | tips)
bar, vending machine, etc.) fot | tena {8% Vmaeqieg! Other |__|
~ 35 048 H {carry-out | ! Dollars \Cents
1 i 1
z So
8 1 i i t
1 42 !3 4 s }
Cc _ L 1 4 H 1
D 1 12 13 ry 1S 1
i i i H n
ALL OTHER PURCHASES AND EXPENSES
Total cost Total cost
ee Hem (Exclude | OFFICE tem (Exclude
ONLY (Describe the item purchased) soles tex) oncy (Describe the stem purchased) sales tox)
Dollars jCents Dollars jCenty
1 Housewares, Furnishings, Hardware, '
Cleaning, Laundry Supplies, 1 and Garden Sui ’ " )
~ ~ plies
25 056 |and Paper Products H 25 080 (mirrors, light bulbs, nails, etc.) H
c nt
A $ Hl A $ I
T 7
B i By; 4
c 1 fe i
D i ° 1
E i € | i
F i F | {
G i G | i
Newspapers, Books, Postage, 1 '
Statlonery, and Schoo! Suppites 1 j Tebacea and Smoking Suppiles !
H $ 1 H | $ 1
J ' J 1
K ‘ K 1
pak itch date Drugs, and i Gas, Oil, Tolls. Parking Fees, H
~ 25 064 | Medical Supplies ~ and Other Vehicle Expenses;
(Indicote if prescribed by o doctor) i 25 098 | apie Transportation Expenses
1 i
A s 1 s 1
B i 8 ——— +
c i H
D T Clothing, Shoes, Jewelry, and Linens + T
“ (such as dress shirts, work shirts, 4
E i casual slacks, etc.) H
F H D $ H
C mG H
H i F 1
3 __|s \
Laundry and Diaper Service, t Rent, Utilities, Fuel, Phone, Insurance Hl
Beauty and Barber Shop, | (Specify period covered by expense, i
Household Help, Babysitters ' such as week, month, year) —y I
K 8 i H ' $
L i J i i
rr 1 K | i
N ' L i {
P Other Purchases and Expenses f
Q (toys, hobbles, contributions, etc.) '
Ry 1 M $ !
Movies, Plays, Other Entertalnment, : N t
Club and Other Membership Duas 1 P 1
1 -_ ‘
(
$ t Q i
t
T Hl R
uv 1 s 1
GIFTS
Yias this purchased!
OFFICE tt for'amenberot | Total cost
USE em this household? (Exclude
ONLY (Describe the item purchased) {Mark one) sales tox)
~ 35071 Yes ; No | Dollars \Cents
A ' F § 1 A
8 ‘ 2 1
c ' 2 1
D ' 2 1
ni H

FORM CE-105 (4-44-72)


Page 16

SEVENTH DAY

ENTER
DAY

Note: If you need additicnal space for any category, use pages 18 and 19.

FOOD AND BEVERAGES
Nomber Net weight Is this Item —
orrice Item ot eana oe & (Mark only one) Total cost
71
USE (Describe the item purchased, such os bottles, | volume per unit Vet gi S| fasclee
. e! =! &! soles rox)
ONLY whole milk, T-bone steak, dried opricots, | packages {Exomples: si gigis
L oll purpose flour, salfines, ete.) ete | Bez. Fer. 2; 2) 8, 8
: § Ibs., etc.) 2; &) SO; =| poltas ‘Cents
~ 57.018 | Dairy and Bakery Products ({adicoté if milk is delivered) tT ot 4 H
A T 2 LEY icy T
| t 1 1 $ 1
t iz 13 Ta T
B | 1 i f |
t Tt
c I v4 Hi C i
. T T Ti
D | PoP PR oe i
E T Hg p hd H
313 t
Ea H
6 1 2 DB Ta H
HW T 2 PB Y H
‘ Tye ty '
K 1 tz ty ta 1
H
Meat,Fish, and Poultry (Indicate the cut of meat) | H t 1 '
H L
‘ 2
L roe fs H
M i) 12 rE 4 ,
. oP 1
N ul (2 13 14 ‘
to L
P ' 2 2B 1a i
oun L 1 LL L
Q y ry 13 \a ’
_ ro 1
R 1 iF 13 a y
Pop \
3 a nn) T
— oop \
T 1 Fy 13 la if T
4 i L {_
uU 4 2 tg 4 T |
_| i i 1
v 7 2 i 8 T
= i I
~ 57.026 | Fruits and Vogatables (Indicote if dried) tot i
T. 3 Ta
A roe fs 1
T. T T r
8 Tea '
c : —_ a ‘
D ra t
- Tata '
F roy? 8 ‘
H
G 1 2 3 ’
L
n 72 te 1
_ 1
7 Tze 1
- ee 1
K rr 1
tt 1
Beverages 1 yt |
_ it L._
L i. 12 B 4 5 ,
tot \
. a) T
po 1
N rr 7
1 4 1
1 (2 13 4 T
P — = n 1 \ !
fy (2 (3 T
Q vor 1
0 12 Ey 4 T
R BoP \
~ 57.034 | All Other Foods tot a
— if T: T
A ia i id $ \
17a Y
ia as r
Tz T 1 T
c T 2 fb H
oa 1
ie t
c Ee t
F ; Te t
Ty 3) I
: 2 3 t
!
; Tf 43.4 i
=" a
K See) t
i
L TT? 3 1
M T4243 “T
toy 1
"i T 12 4 1
1 1 1
P 1 2 8 f
Lot \
3 ea {
4 1 n 1
R Tie (
ib t
FORM CE-105 (4-11-72)