Feb. 19.] THE NEW ZEALAND GAZETTE. 505

In addition to the aforementioned districts, the Chatham Islands are hereby constituted a district under the name of the Chatham Islands District.

Outlying islands not included in any of the abovementioned boundaries shall be deemed to form part of the district to which they are adjacent.

69. In the case of the abovementioned districts, with the exception of Auckland, Wellington, Christchurch, Dunedin, and Invercargill, the Deputy Registrar shall be the person for the time being holding the office of Clerk of the Court for the Magistrate’s Court held in the town bearing the same name as the name of the district.

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SCHEDULE.
[Form 1 (Reg. 2).]

Under “The Old-age Pensions Act, 1898,” and Amendment Acts, 1900, 1901, and 1902.

PENSION-CLAIM.

I, THE undersigned, make claim for a pension under the aforesaid Acts, and in support thereof do hereby solemnly and sincerely declare as follows:—

My full name is:
My full address is: [Place of residence and postal address], in the Old-age Pension District of
My occupation is [If of no present occupation, say so, and state the last.]
I was born at [Place], in [Country], on the day of , 18 , and my age last birthday was years.
[Produce certificate of your birth.]
I first arrived in New Zealand in 18 , from , in the ship [Name of ship, and, if possible, name of captain. If the claimant was born in New Zealand this paragraph may be struck out, or left in blank]. The captain’s name was .
Give name and address of person of good character who came to New Zealand in ship with you and who can verify your statements:
Since I first arrived in New Zealand I have been absent from the colony on [Set out number] occasions.
My total absences from New Zealand since I first arrived amount to years, made up as follows:—

Particulars.
[Set out in respect of each occasion the date and port of departure, the ship and destination, and also the date and port of return, and the name of the ship. If the claimant has not been absent from the colony at all during the twenty-five years he must alter this paragraph to express the fact.]
Where have you lived before?
How long did you live there?
Name a person of long residence and good character residing there who can verify your statements (Deputy Registrar to use Form H.):
State how long such person has known you:
Are you a naturalised subject? If so, produce papers:
Have you made previous application for a pension?
If so, why was application not granted?
Are you married? [State whether single, married, widow, or widower.]
If so, give full name and address of your husband [or wife]: [Full name and address important.]
If married, is your husband [or wife] an old-age pensioner?
Why is your husband [or wife] not an old-age pensioner?
Is your husband [or wife] possessed of property, income, or money?
State particulars and value:
If property mortgaged, give number, date, name, and address of mortgagee:
Are you living together? If not, why?

Are you the owner of money—

{Deputy Registrar to use Forms B and D.}
{Form D.} In Post-Office Savings-Bank ..
{Form B.} In any other bank? ..
In Bank of New Zealand? ..
In Bank of New South Wales? ..
In Bank of Australasia? ..
In Union Bank of Australia? ..
In National Bank of New Zealand? ..
In any other monetary institution? ..
In any building society? ..
Not in banks or building societies? ..

Amount in Credit. | Amount withdrawn. | Date withdrawn. | Name of Town Account kept in.

{Deputy Registrar to use Forms C and F.}
Form C. Are you the owner of—
Land (freehold)? ..
” (leasehold)? ..
Houses (freehold)? ..
” (leasehold)? ..
Have you any interest in—
Land (freehold)? ..
” (leasehold)? ..
Houses (freehold)? ..
” (leasehold)? ..

Value. | Local District or Borough. | No. of Section, or Allotment, Street, or particular Locality. | Area. | A. R. P.

Form F. Have you transferred any—
Land (freehold)? ..
Land (leasehold)? ..
Houses (freehold)? ..
” (leasehold)? ..
Have you transferred your interest in—
Land (freehold)? ..
” (leasehold)? ..
Houses (freehold)? ..
” (leasehold)? ..

Value. | Local District or Borough. | No. of Section or Allotment, Street, or particular Locality. | Area. | A. R. P. | Name and Address of Person to whom transferred, and Date of Transfer.

Form C. What money is owing by you on mortgage?
Give name and address of person to whom money is owing:
Give number and date of mortgage:
Have you money lent out on mortgage?
State amount and to whom lent out:
Give particulars of property on which money so lent:
Are you the owner of live-stock? Give particulars and value:
Are you the owner of mining shares, debentures, bonds, or stock in any company or other institution or building society? [Give number of shares and value of same; name of company, institution, or building society; where registered; and address.]
Have you transferred any shares or your interest in any of the above-named securities? [Give particulars and value; name and address of person you transferred to; and date when transferred.]
Have you been left any money or any other valuable consideration of any kind at any time? [Give full particulars and amount, and date when money or valuable consideration received by you.]
Are you in receipt of an Imperial pension? Give amount:
Are you in receipt of board and lodgings free? If you are, give name and address of person providing same:

{Deputy Registrar to use Form I.}
Form I. A pension or annuity of any kind other than an old-age pension?
Is your life insured? Name company and amount insured for:
Have you received money under any life policy?
If so, state amount and name of office, and date when received:

Form G. What did you earn last year?
How did you earn it?
Name and address of person from whom earned:
State value of your furniture, personal effects, jewellery, &c.:
If you have transferred furniture, personal effects, jewellery, &c., give name transferred to, and value:
Do you receive rents from any source? Give particulars:
Have you ever transferred your interest in any business to any one? If so, give particulars of the business, its value, and name and address of person you transferred it to, and date:
Are you in receipt of any allowance from your children or any other person?
Give name and address of children or person granting you the allowance, and state amount:

Form H. Section 8, subsections 2, 3, 4, 5, 6, 7, 8, &c.