2298
THE NEW ZEALAND GAZETTE.
[No. 105

Total wages .. .. .. .. .. £
Total of other personal earnings.. .. ..
Total income from all other sources except from
accumulated property .. .. ..

Total income from all sources except from ac-
cumulated property .. .. ..

[If the pensioner himself has received no income for the year,
this paragraph is to be marked “Nil.”]

3. To the best of my knowledge and belief my wife’s (or
   husband’s) income for the aforesaid income-year was
   and no more, and was derived from the following sources,
   viz. :-

Total wages .. .. .. .. .. £
Total of other personal earnings.. .. ..
Total income from all other sources except from
accumulated property .. .. ..

Total income from all sources except from ac-
cumulated property .. .. ..

[This paragraph is to be struck out if the pensioner is un-
married, or if husband and wife are living apart pursuant to
decree, order, or deed of separation; and is to be marked “Nil”
if no income has been received.]

4. The net capital value of all the accumulated property
   owned by me on the day of (being the day of
   the expiry of the aforesaid income-year) is estimated by me
   at £ , and no more, and the following are the par-
   ticulars thereof :-

[If the pensioner has no accumulated property this para-
graph is to be marked “Nil.”]

And I make this solemn declaration conscientiously be-
lieving the same to be true, and by virtue of the provisions
of an Act of the General Assembly of New Zealand intituled
“The Justices of the Peace Act, 1882.”

Declared by the said , at ,
this day of , 1 , before
me— , Justice of the Peace
[or as the case may be, Solicitor, ..........
or Deputy Registrar for the Claimant.
Old-age Pension District, or Post-
master at (Name of post-town)].

To the Deputy Registrar for the Old-age
Pension District.

INSTRUCTIONS TO PENSIONERS IN THE FILLING-UP OF
THEIR INCOME AND PROPERTY STATEMENTS.

[To be printed at foot or on back of the Statement.]

By section 2 of the Act “income” and “income-year”
are defined as follows :-

[Set out the definitions.]

By section 10 of the Act the following provisions apply in
the computation and assessment of the net capital value of
accumulated property :-

[Set out subsections (1) and (2).]

By section 12 of the Act the following provisions apply
with respect to income :-

[Set out the section.]

By section 13 of the Act the following general rules apply
in the computation of income :-

[Set out subsections (1), (2), and (3).]

By section 35 of the Act it is provided that the pensioner
shall furnish his Income and Property Statement each year,
whether claiming any payment in respect of his pension for
the year or not.

—

Form 24 (Reg. 38).

Under “The Old-age Pensions Act, 1898.”

CIRCULAR AS TO INCOME AND PROPERTY STATEMENT.

To

THE year for which your pension-certificate, No. , was
granted will expire on the day of , 1 ,
and, in order to ascertain whether you are entitled to a
pension-certificate for the ensuing year, and, if so, for what
amount, you must fill up the accompanying Income and
Property Statement for the income-year ending on the
day of , 1 , and send it to the Deputy Registrar at
within seventeen days after the close of that
income-year.

You must fill up and send in the Statement whether you
claim a pension-certificate for the ensuing year or not.

Dated at , this day of , 1 .

............

Registrar.

—

Form 25 (Reg. 39).

Under Subsection (4) of Section 35 of “The Old-age Pen-
sions Act, 1898.”

STIPENDIARY MAGISTRATE’S CERTIFICATE AS TO PENSIONER’S
INCOME AND PROPERTY STATEMENT, ETC.

To the Deputy Registrar for the Old-age Pension
District.

I HEREBY certify that I have investigated the Income and
Property Statement of for the income-year ended
the day of , 1 , and am satisfied on the
following points :-

1. The pensioner’s income for the income-year was £ .
2. The net capital value of his accumulated property as at
   the end of the income-year was £ .
3. The conditions of section 8 of the aforesaid Act have
   been complied with [or, as the case may be, have not been
   complied with in so far as relates to subsection(s) num-
   bered of that section].
4. For the year commencing on the day of ,
   1 , the pensioner is entitled to a pension of £ ,
   payable by twelve equal monthly instalments of £ ,
   at the Post-office Money-order Office [or, as the case
   may be, is not entitled to a pension].

Dated at , this day of , 1 .

............

Stipendiary Magistrate.

—

Form 26 (Reg. 41).

Under “The Old-age Pensions Act, 1898.”

STATEMENT TO BE FURNISHED BY MAORI CLAIMANT OR
PENSIONER.

PARTICULARS of all land in respect of which I claim or
possess any customary rights or any interest :-

PAPATUPU LAND
(Meaning Land the Title to which has not been ascertained
by the Native Land Court or otherwise).

LAND HELD UNDER DEFINED LEGAL TITLE.

This statement refers to my pension-claim [or, as the case
may be, Income and Property Statement] bearing date the
day of , 19 .

Dated at , this day of , 19 .

............

[Signature.]

As witness the hand of His Excellency the Governor,
this fifteenth day of December, one thousand
eight hundred and ninety-nine.

T. THOMPSON,
For Colonial Treasurer.

By Authority: JOHN MACKAY, Government Printer, Wellington.