Feb. 19.] THE NEW ZEALAND GAZETTE. 513

My full name is .
My full address is .
My present occupation is .
My former occupation was .
The number of my pension is , registered in the Old-age Pension District.

For the period above named my total income and earnings was as follows:—

Wages .. .. .. .. £ s. d.
Other personal earnings .. .. .. : :
Income from all other sources except from property .. .. .. .. : :
Estimated cost of free board and lodgings .. .. : :

Total .. .. .. £ : :

The name and address of the person from whom I earned income is .

The property owned by me is as follows:— Value.
Real property [Description] .. .. .. £
Personal property [Description] .. .. .. £
The rates and charges on this property amount to £
The property is mortgaged to , [Address], for the sum of . The registered number and date of mortgage are .

The full name, address, occupation, and amount of pension of my husband [or wife] are,—
Name:
Address:
Occupation: Amount of pension: £ .

For the period above named the total income and earnings of my husband [or wife] was,— £ s. d.
Wages .. .. .. .. : :
Other personal earnings .. .. .. : :
Income from all other sources except property.. .. : :
Estimated cost of free board and lodgings .. .. : :

Total .. .. .. £ : :

The name and address of the person from whom my husband [or wife] earned income is .

The property owned by my husband [or wife] is as follows:— Value.
Real property [Description] .. .. .. £
Personal property [Description] .. .. .. £
The rates and charges on this property amount to £
The property is mortgaged to , [Address], for the sum of £ . The registered number and date of mortgage are .

[Please answer questions hereunder, and give particulars.]

What money have you in Post-Office Savings-Bank or other bank?

What insurance-money have you received during the past year?

Have you lent or transferred any money during the past year?

Have you purchased an annuity during the past year?

Have you transferred or sold any property during the past year?

Have you been left any money or property of any kind during the past year?

What money has your husband [or wife] in the Post-Office Savings Bank or other bank?

What insurance-money has your husband [or wife] received during the past year?

Has your husband [or wife] lent or transferred any money during the past year?

Has your husband [or wife] purchased an annuity during the past year?

Has your husband [or wife] transferred or sold any property during the past year?

Has your husband [or wife] been left any money or property of any kind during the past year?

I solemnly and sincerely declare as follows:—

1. That the contents of this my application for renewal of pension are correct in every detail.
2. That, 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.

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.”

Declared by the said , Claimant.
, at , this day of , 19 , before me—
Justice of the Peace.
Solicitor.
Deputy Registrar at .
Postmaster at .

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

[Not to be filled in by the Pensioner.]

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 .. .. .. .. £

(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 , Esq., Stipendiary Magistrate at .

I hereby certify that, as far as I have been able to do so with the forms at my disposal, I have verified the statements of pensioner; and, having ascertained that the requirements of section 8 of the original Act have [not] been complied with, I recommend that [no] pension be granted for the sum of £ , being the full amount of pension reduced by £ for property and £ for income.

, Deputy Registrar for the Old-age Pension District of .

Date: , 19 .

Form 20 (Reg. 40).

District.

LIST OF PENSIONERS TO WHOM FORMS OF INCOME AND PROPERTY STATEMENT ARE TO BE POSTED FOR THE INCOME-YEAR ENDING , 19 .

This form is to be returned to me, duly completed.
, Registrar.

Form 21 (Reg. 40).

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

CIRCULAR AS TO INCOME AND PROPERTY STATEMENT.

To .

THE year for which your pension-certificate, No. was granted will expire on the day of , 19 , and, in order to ascertain whether you are entitled to a pension-certificate for the ensuing year, and, if so, for what amount, you must fill up the accompanying income and property statement for the income-year ending on the day of , 19 , and send it to the Deputy Registrar at immediately after the close of the said income-year.

You must fill up and send in the statement whether you claim a pension-certificate for the ensuing year or not.

If the application is not sent in by the day of , 19 , your name will be struck off the pension-roll.

Dated at , this day of , 19 .
, Deputy Registrar of the Old-age Pension District.