508
THE NEW ZEALAND GAZETTE.
[No. 12

"The Old-age Pensions Act, 1898," and Amendment Acts, 1900, 1901, and 1902.

To be filled in by the Deputy Registrar.

To be filled in by the District Land Registrar or Registrar of Deeds.

Have the Persons named, at any time since 1898, transferred any Property, Freehold or Leasehold, or any Interest in same, or Mortgage, &c.?

(To be used in each case by Deputy Registrar.)
[Form G.

Under "The Old-age Pensions Act Amendment Act, 1901," Section 3.

From the Deputy Registrar, Old-age Pensions, at
, to
An application for an old-age pension [or renewal of pension] having been made by Mr.
, I desire to know what he earned while in your employ during the past twelve months ended
, 19
, Deputy Registrar.

From Mr.
to the Deputy Registrar, Old-age Pensions, at
.
Mr.
was in my employ for the
, and during that period he earned the sum of £
.
Signature :
.

[Form H.

Under "The Old-age Pensions Act, 1898."

From the Deputy Registrar, Old-age Pensions, at
, to Mr.
.
Mr.
, an applicant for an old-age pension, states that you have known him for a period of
years.
, Deputy Registrar.

From Mr.
to the Deputy Registrar, Old-age Pensions, at
.
I HAVE known Mr.
for a period of
years, and during that time his character was
.
Signature :
.

NOTE.—In all cases where the person referred to by the applicant is resident in another district, this form is to be sent through the Deputy Registrar for that district, by whom it is to be returned to the Deputy Registrar seeking the information.

Confidential.]
[Form I.

Under the Old-age Pensions Acts, 1898, 1900, 1901, and 1902.

From the Deputy Registrar, Old-age Pensions, to the
Life Insurance
.
As the persons named herein have made application for pensions* [or renewal of their pensions, or are drawing pensions] under the above Acts, I shall be obliged if you will supply particulars as set out in the Schedule herein.
The information is required in terms of section 3 of "The Old-age Pensions Amendment Act, 1901."
Please return the form to me when duly completed.
, Deputy Registrar.
, 19
.

• Delete where necessary.

From the
Life Insurance
, to the Deputy Registrar, Old-age Pensions,
.
INFORMATION herewith, as requested.
Signature :
.
Date :
, 19
.
NOTE FOR DEPUTY REGISTRAR.—This form is to be used before claim is considered by Stipendiary Magistrate.

In Name of Applicant.

In Name of Husband or Wife.

Note for Deputy Registrar.

If the required information is not obtainable locally, refer to head offices as under :
Australian Mutual Provident Society, Wellington.
Australian Widows' Fund Life Assurance Society, Wellington.
Citizens' Life Assurance Company, Wellington.
Colonial Mutual Life Assurance Company, Wellington.
Equitable Life Assurance Company, Wellington.
Government Insurance Department, Wellington.
Mutual Life Association of Australasia, Wellington.
National Mutual Life Association of Australasia, Wellington.
New York Life Insurance Company, Wellington.
T. and G. Mutual Life Society, Wellington.

[Form 1A (Reg. 14).

Under the Old-age Pensions Acts, 1898, 1900, 1901, and 1902.

STATEMENT TO BE FURNISHED BY MAORI CLAIMANT OR PENSIONER.

Full name of claimant [Give all names known by] :
Address :
Name of tribe or hapu :

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).