512
THE NEW ZEALAND GAZETTE.
[No. 12

and in support of this application I hereby declare that the
reason why the instalment in question was not collected is
as follows: [If the applicant is an agent he shall state
whether pensioner is alive, and give address.]

Signature:
Date:

Witness:
Occupation:
Address:

The Registrar of Old-age Pensions, Wellington.
I have examined the pension-certificate and find that
payment of the instalment applied for is not recorded thereon.
[Deputy Registrar to here state whether he recommends pay-
ment, and give reason].

, Deputy Registrar at

——

Form 15 (Reg. 36).

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

APPLICATION FOR PAYMENT OF PORTION OF INSTALMENT
OF PENSION ACCRUED UP TO DATE OF DEATH OF PEN-
SIONER.

To the Registrar,
I, [Name of applicant], of , do hereby apply for pay-
ment of the portion of instalment accrued on account of
pension-certificate No. , issued to [Name of pen-
sioner], in the Old-age Pension District, who died on
the day of , 19 .
I enclose receipt for £ for funeral expenses of the
above-named pensioner, which have been paid by me.
The pension-certificate is forwarded herewith to enable
payment to be made.
Dated at , this day of , 19 .
, Applicant.

The Registrar.
This pensioner died in such circumstances that no money
was left in his estate whereby funeral expenses could be paid,
and I recommend payment being made to the applicant, who
defrayed the cost of same.

, Deputy Registrar at

——

Form 16 (Reg. 37).

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 instal-
ments of pensions as specified in the following schedule, that
is to say:—

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 conscientiously be-
   lieving 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.”
   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].

Warrant under Section 43.
Warrant accordingly herewith for the total sum of £
in terms of the application.
Dated at , this day of , 19 .
, Stipendiary Magistrate.
(To be retained by the Postmaster, and forwarded with his
accounts.)

Form 17 (Reg. 38).

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 Pen-
sion 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 , 19 .
, Applicant.

[In the event of the proposed payee being established in
business, Form 17a shall be filled in and signed by the pen-
sioner, and posted to Registrar at Wellington.]

Proposed payee:

I consent hereto.

Pensioner:

NOTE.—A warrant under section 44 shall not be issued in
respect of any pensioner who is an inmate of any charitable
institution, warrant under section 43 being used for that
purpose.

——

Form 17A (Reg. 38).

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

RE APPLICATION FOR WARRANT UNDER SECTION 44.

Pension No.:
District:

NOTE.—Pensioners may receive instalments of their pen-
sions at the post-office nearest to their residence by having
them remitted from the nearest money-order office by regis-
tered letter.
Name of pensioner:
Occupation:
Address:

I, THE above-named pensioner, do hereby declare as fol-
lows:—

1. That the nearest post-office to my residence—namely,
   , is too far distant to be convenient for me to
   receive my pension thereat in person.
2. That it is my express desire that instalments of my
   pension shall be collected by Mr. , carrying on
   business as [Occupation] at [Address].
3. That there is no other means whereby I can receive the
   said instalments.

Signature:
Date:

Witness:
Occupation:
Address:

The Registrar, Wellington.
Warrant under section 44 has been granted as desired
above, the first instalment to be collected thereunder being
that due the 1st , 19 .
, Deputy Registrar.

Date: , 19 .

——

Form 18 (Reg. 38).

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

WARRANT UNDER SECTION 44.

(Not to be issued in respect of any pensioner who is an
inmate of a charitable institution.)

PURSUANT to application in this behalf I hereby grant this
warrant, directing that until the same is cancelled all instal-
ments of the pension payable to [Full name of pensioner],
pursuant to pension-certificate No. , which expires
on the 1st day of , 19 , shall be payable to [Full
name, occupation, and address of payee], for the benefit of
the pensioner.
Dated at , this day of , 19 .
, Stipendiary Magistrate.

NOTE.—This warrant is available only for the pension-
certificate current at date of its issue, and requires to be
renewed at each renewal of the pension.

——

Form 19 (Reg. 39).

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

INCOME AND PROPERTY STATEMENT FOR THE INCOME-YEAR
ENDED THE DAY OF , 19

(Being the day one month prior to the anniversary of the
establishment of the claim).

I, THE undersigned, make claim for the renewal of my
pension under the aforesaid Acts, to be made payable at
the Post-Office Money-order Office, and in support
thereof do hereby solemnly and sincerely declare as fol-
lows:—