506
THE NEW ZEALAND GAZETTE.
[No. 12

I solemnly and sincerely declare—

1. That I clearly understood the questions; and my answers are true and correct.
2. To the best of my knowledge and belief I have fulfilled all the requirements and am exempt from all the disqualifications under the aforesaid Acts up to the date of this my pension-claim, and am entitled to a pension.
3. The contents of this my pension-claim are true and correct in every material point.
   And I make this solemn declaration conscientiously believing 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.”
   , Claimant.
   Declared by the said , at , this day of , 19 , before me—
   , Justice of the Peace.
   , Solicitor.
   , Deputy Registrar for the Old-age Pension District.
   , Postmaster at [Name of post-town].
   To the Deputy Registrar for the Old-age Pension District.
   (Not to be filled in by the Applicant.)
   Gross value of property of applicant .. .. £
   Less allowance by Act .. .. £50
   Less charges and encumbrances .. £
   ——
   Net value .. .. .. £
   Gross value of property of applicant’s husband [or wife] .. .. .. £
   Less allowance by Act .. .. £50
   Less charges and encumbrances .. £
   ——
   Net value .. .. .. £
   ——
   Total net values .. .. £
   ——
   Total income of applicant .. .. .. £
   Total income of applicant’s husband [or wife] £
   ——
   Total .. .. .. .. £
   ——
   NOTE.—
   (a.) If applicant is single, a widow, or widower, reduce pension by £1 for every £15 in net value of property, and by £1 for every £1 in income exceeding £34.
   (b.) If applicant is married, and husband or wife has neither property or income, reduce as in (a).
   (c.) If applicant is married, without property or income, but husband or wife, has either reduce pension by £1 for every £15 in half of net value of property, and by £1 for every £1 in half of income exceeding £34.
   (d.) If applicant is married and has property or income as well as husband [or wife], reduce pension by £1 for every £15 in half of total net values of property, and by £1 for every £1 in half of total incomes exceeding £34, except—
   (1.) Where the value of applicant’s property exceeds the said half, then reduce on the larger amount; and
   (2.) Where applicant’s income exceeds the said half, then reduce also on the larger amount:
   Provided that in no instance shall the total incomes of husband and wife, together with pension granted to either of them, exceed £78.
   To , Esquire, Stipendiary Magistrate at .
   SIR,—
   I hereby certify that I have read over the within questions and answers to the claimant, and he appears to clearly understand the meaning thereof. Form E is attached hereto, and, as far as I have been able to do so, I have verified the statements of claimant by— .
   Form B.—Sent out to the various banks, and returned to me duly answered.
   Form C.—Sent to the Registrar, who has procured the required information from the Commissioner of Taxes at Wellington, and returned the form to me.
   Form D.—Sent out to Chief Postmaster, who has supplied from the Post-Office Savings-Bank Accounts the required information, and returned the form to me.
   Form E (Attached herewith). — Under section 8, subsections (2), (3), (4), (5), (6), (7), (8), &c.
   Form F.—Sent out to District Land Registrar or Registrar of Deeds ; information supplied, and form returned to me.
   Form G.—Sent out to employer ; information supplied, and form returned to me.
   Form H.—Sent out to person of long residence and good character referred to by applicant, and returned to me.
   Form I.—Sent out to various insurances companies, and returned to me duly completed.
   , Deputy Registrar.
   Date: , 19 .

Confidential.]
[Form B.
(This form is to be sent by Deputy Registrar to each bank.)
“ The Old-age Pensions Act, 1898,” and Amendment Act, 1901.
From the Deputy Registrar, Old-age Pensions, , to the Manager, Bank of .
SIR,—
As the persons mentioned in the Schedule within have made application for a pension [or are drawing a pension] under the above-named Acts, I have the honour to request that you will be kind enough to answer the questions asked within, opposite the name of each applicant. This information is required in accordance with section 3 of “ The Old-age Pensions Amendment Act, 1901.”
Please return this form to me when the questions have been answered by you.
, Deputy Registrar.
“ The Old-age Pensions Amendment Act, 1901.”
Duty to answer Questions respecting Applications.
Clause 3. (1.) It shall be the duty of every person to make true answers to all questions concerning any applicant for a pension or renewal, or any of the statements contained in any application for a pension or renewal certificate put to him by the Deputy Registrar or any officer authorised in that behalf by the Deputy Registrar.
(2.) Every person commits an offence who—
(a.) Refuses to answer any such question; or
(b.) Makes any answer knowing the same to be untrue.
(3.) This section shall apply to any officer of any bank or other corporation carrying on business in New Zealand, and to any officer of the Post-Office Savings-Bank and of any other Government Department which receives investments of money from the public.
PLEASE state in writing, on line opposite names given below, if persons so named have any money of any kind lying in your bank; if on fixed deposit or current account, say so; if in shares or other valuable security, say so; if money has been withdrawn at any time, state amount withdrawn, and give date :—

(Before a Pension is granted this form must be sent to Head Office, where the information will be quickly procured and form returned to you.)
[Form C.
“ The Old-age Pensions Act, 1898,” and Amendment Acts, 1900, 1901, and 1902.
From the Deputy Registrar, Old-age Pensions, to the Registrar of Old-age Pensions, Wellington.
SIR,—
As the persons mentioned in the Schedule within have made application for a pension [or are drawing a pension] under the above-named Acts, I have the honour to request that you will cause inquiry to be made from the Commissioner of Taxes in Wellington to enable me to say if each applicant is entitled to receive a pension.
Please return this form to me when the questions have been answered by the Land- and Income-tax Department.
, Deputy Registrar.
PARTICULARS of Money now lent out on Registered Mortgage (Money lent out on Mortgage at any time, but which may not now be standing in their Names in your Books); give Amount so lent out, and Date when struck out of your Books.