Dec. 13.] THE NEW ZEALAND GAZETTE. 2235

to (Full name of pensioner) pursuant to Pension-certificate No. , hereby apply for a transfer of the pension-certificate from this district to the Old-age Pension District, on the grounds [Set out briefly but clearly the grounds].
It is desired that the post-office of payment in the new district should be at
Dated at , this day of , 1 .
Applicant.

—
Form 12 (Reg. 18).

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

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

No. of pension-certificate transferred :
Name of pensioner :
Name of payee [if other than the pensioner], and date and currency of the warrant or order under which he is entitled :
Name of district to which transfer is made :
Due date of next instalment :
Name of post-office in new district for payment of future instalments :

THIS transfer is recorded in my register as on this date. Kindly make the necessary entries in your register in order to complete the transfer.
Dated at , this day of , 1 .
Deputy Registrar for the Old-age Pension District.

—
Form 13 (Reg. 19):

Under “The Old-age Pensions Act, 1898.”
RECEIPT FOR PAYMENT OF INSTALMENT.

Name of old-age pension district :
Full name of pensioner :
Number of pension-certificate :
Number of instalment :
Amount thereof :
Due date thereof :
Name of payee [If other than the pensioner, state also the date of the warrant or order entitling the payee to receive payment] :

RECEIVED above instalment accordingly from the Postmaster at , this day of , 1 [If payee is other than the pensioner, add, and I certify that, to the best of my knowledge and belief, the pensioner was, when the instalment became due, residing in the colony, and this instalment is properly payable].

—
Form 14 (Reg. 21).

Under “The Old-age Pensions Act, 1898.”
APPLICATION TO REGISTRAR FOR PAYMENT OF FORFEITED INSTALMENT.

I, , of , being the pensioner [or, as the case may be, the authorised payee] under Pension-certificate No. , hereby apply for payment of the forfeited instalment No. , for , which was due on the first day of , 1 , at the post-office at , and has become forfeited by lapse of time; and in support of this application I hereby solemnly and sincerely declare as follows:—
[Here set out briefly but clearly the reasons why the instalment was not applied for in due time.]
And I make, &c. [as in the case of a pension-claim].

—
Form 15 (Reg. 23).

Under “The Old-age Pensions Act, 1898.”
APPLICATION to Stipendiary Magistrate for Warrant, under Section 43, for Payment of Instalment to Charitable Institution.

On behalf of the [Name of the charitable institution], I, , Secretary [Treasurer, or member of the governing body] of the said institution, hereby make application to , Esquire, Stipendiary Magistrate, for a warrant authorising the payment to the said institution of the instalments of pensions as specified in the following Schedule, that is to say :—

B

And in support of this application I hereby solemnly and sincerely declare as follows :—

1. The said institution has, in the case of each pensioner, maintained or relieved him for the period set forth opposite his name in the foregoing Schedule, and the reasonable cost thereof is as therein mentioned.
2. I believe that each of the pensioners is entitled to his instalment.
   And I make this solemn declaration, &c. [as in the case of a pension-claim].

—
Form 16 (Reg. 23).

WARRANT UNDER SECTION 43.

[To be subscribed to or indorsed on the application.]
WARRANT accordingly herewith in terms of the application.
Dated at , this day of , 1 .
Stipendiary Magistrate.

—
Form 17 (Reg. 24).

Under “The Old-age Pensions Act, 1898.”
APPLICATION TO STIPENDIARY MAGISTRATE FOR WARRANT UNDER SECTION 44.

I, [Full name, occupation, and address of applicant], hereby apply to , Esquire, Stipendiary Magistrate, for a warrant under section 44 of the aforesaid Act directing that until the warrant is cancelled all instalments of the pension payable to [Full name of pensioner] pursuant to Pension-certificate No. , of the Old-age Pension District, may be paid to [Full name, occupation, and address of proposed payee], for the benefit of the pensioner, on the grounds [Set out briefly but clearly the grounds].
Dated at , this day of , 1 .
Applicant.

I consent hereto.
[Proposed payee.]

I consent hereto.
[Pensioner.]

—
Form 18 (Reg. 24).

Under “The Old-age Pensions Act, 1898.”
WARRANT UNDER SECTION 44.

PURSUANT to application in this behalf I hereby grant this warrant directing that until the same is cancelled by a Stipendiary Magistrate all instalments of the pension payable to [Full name of pensioner], pursuant to pension-certificate No. , or any future pension-certificate, shall be payable to [Full name, occupation, and address of payee] for the benefit of the pensioner.
Dated at , this day of , 1 .
Stipendiary Magistrate.

—
Form 19 (Reg. 26).

Under “The Old-age Pensions Act, 1898.”
APPLICATION FOR CHANGE OF OFFICE OF PAYMENT.

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

I, [Full name, occupation, and address of applicant], being the pensioner [or, as the case may be, the authorised payee of the instalments of the pension payable to (Full name of pensioner) pursuant to Pension-certificate No. ], hereby apply that the office of payment may be changed from to , on the grounds [Set out briefly but clearly the grounds].
Dated at , this day of , 1 .
Applicant.

—
Form 20 (Reg. 28).

Under “The Old-age Pensions Act, 1898.”
INCOME AND PROPERTY STATEMENT FOR THE INCOME-YEAR ENDING ON THE DAY OF , 1 .

I, , of , do solemnly and sincerely declare as follows :—

1. I am a pensioner under the aforesaid Act pursuant to Pension-certificate No. , registered in the Old-age Pension District.
2. For the income-year ending on the day of , 1 , my income 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 accumulated property .. .. ..

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