Feb. 19.] THE NEW ZEALAND GAZETTE. 509

Land held under Defined Legal Title.

My land is leased to Mr. , [Occupation], of [Address], who pays me a yearly rent of £ .

Land previously held by me.

Name, acreage, and locality of block :

Nature and extent of share or interest previously held by me :

Name under which I previously held such share or interest :

How disposed of (whether by sale or gift) :

Amount of consideration :

Terms and conditions on which disposed of :

Name and address of person to whom sold or otherwise disposed of :

[To be filled in if Maori claimant or pensioner is married.]

Full name of husband [or wife] [Give all names known by] :

Address :

Name of tribe or hapu :

PARTICULARS of all land in respect of which my husband [or wife] claims or possesses 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.

My husband’s [or wife’s] land is leased to Mr. , [Occupation], of [Address], who pays therefor a yearly rent of £ .

Land previously held by my Husband [or Wife].

Name, acreage, and locality of block :

Nature and extent of share or interest previously held by my husband [or wife] :

Name under which my husband [or wife] previously held such share or interest :

How disposed of (whether by sale or gift) :

Amount of consideration :

Terms and conditions on which disposed of :

Name and address of person to whom sold or otherwise disposed of :

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 : .

Pensions Claim No. . [Form 1b (Reg. 18).]

District : .

Under Section 8 of “The Old-age Pensions Act Amendment Act, 1902.”

PENSION-CLAIM.

I, THE undersigned, having duly made application for a pension on Pension-claim Form No. 1, giving full and true particulars of all my property, money, and income, as required by the provisions of “The Old-age Pensions Act, 1898,” and its amendments, do hereby desire to avail myself of the provisions of section 8 of “The Old-age Pensions Act Amendment Act, 1902,” and do hereby agree to convey or transfer the freehold property on which I am at present residing to the Public Trustee, who shall deal therewith as directed by the aforesaid section 8 of “The Old-age Pensions Act, 1902,” and “The Public Trust Office Consolidation Act, 1894.”

My name is .

The full name of my husband or wife is .

My address is .

The address of my husband or wife is .

My occupation is (or was) .

I am already an old-age pensioner, pursuant to Pension Certificate No. ; [or, as the case may be, I have never received an old-age pension].

The property I desire to be conveyed or transferred to the Public Trustee, to enable me to receive a pension, is as follows :—

I am aware of, and agree to conform to, the following conditions :—

1. That I will continue to reside on the property.
2. That I will keep the property in good order and repair.
3. That I will pay all rates and taxes and charges on the property.
4. That I will not let or lease any part of the property.
5. That I will keep the property insured for its full insurable value.

Signature : .

Address : .

Witness : .

Occupation : .

Address : .

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

THE REGISTRAR.

Herewith please find application under section 8 of “The Old-age Pensions Act Amendment Act, 1902.” Applicant has fulfilled all the requirements, and, with the exception of property, is exempt from all disqualifications under “The Old-age Pensions Act, 1898,” and its amendments.

, Deputy Registrar.

THE PUBLIC TRUSTEE.

I certify that the following is a copy of the entry in the General Valuation Roll in connection with this property :—

Date : .

, Registrar, Old-age Pensions.

THE REGISTRAR, OLD-AGE PENSIONS.

I am prepared to accept the deeds of the said property as security for any pension that may be granted.

Date : .

, Public Trustee.

THE REGISTRAR.

I hereby certify that I have investigated the claim herein, and you are hereby authorised to issue a pension certificate for one year’s pension of £ (subject to the transfer of the property to the Public Trustee), payable at the Post-office Money-order Office.