JAN. 31.] THE NEW ZEALAND GAZETTE. 389

In addition to the aforementioned districts, the Chatham
Islands are hereby constituted a district under the name of
the "Chatham Islands District."

Outlying islands not included in any of the above-men-
tioned boundaries shall be deemed to form part of the district
to which they are adjacent.

71. In the case of the above-mentioned districts, with the
    exception of Auckland, Wellington, Christchurch, Dunedin,
    and Invercargill, the Registrar shall be the person for the
    time being holding the office of Clerk of the Court for the
    Magistrate's Court holden in the town bearing the same
    name as the name of the district.

FIRST SCHEDULE.
[Form 1 (Reg. 2).
[This form is to be issued only to or on behalf of a bona fide
applicant for pension.]

Under the Old-age Pensions Acts, 1908 and 1909.

PENSION-CLAIM. [No. .

To the Registrar for the Old-age Pension District.

I, THE undersigned, hereby make claim for an old-age pension
under the aforesaid Acts.

My full name is .
My full address is .
My occupation is [or was] .
I was born at [Town or parish], in the Country of ,
on the day of , 18 , and my age last
birthday was years.
[Produce certificate of your birth, marriage, or of
birth of child, or any document showing your age.]

I am a British subject [State if by birth or naturalisation].
[If naturalised, give date and place of naturalisation.
Produce naturalisation papers.]
I first arrived in New Zealand on the day of ,
18 , at the Port of , in the ship " ,"
which sailed from . The captain's name was

[Registrar to use Form A.]

Since I first arrived in New Zealand I have been absent from
New Zealand on the following occasions:—
Date of departure: . Port of departure: .
Name of ship: " ."
Date of return: . Port returned to: .
Name of ship: " ." Period absent: [Years,
months].

I have lived in the following towns or districts in New
Zealand, and the person named against each place can
verify my residence there:—
Town or district: .
Actual years of residence: .
Name and address of person who can verify my residence
there: .

[Registrar to use Form H.]

I have [or have not] made previous application for the
pension at .
I am [State whether single, married, a widow, or widower].
[If married, give date and place of marriage.]
The full name and address of my husband [wife—to include
maiden name] is [or was] .
My husband [wife] is [or is not] an old-age pensioner. [If
not an old-age pensioner, give reason.]
We are [or are not] living together. [If not living together,
state if separated by decree, order, or deed of separation,
and how long.]

The income of myself and of my husband [wife] during the
past twelve months preceding this date is as follows:—
Received by myself. Received by my husband [wife],—

1. Salary, wages, or other personal earnings: £
2. Military, civil, superannuation, or other pension (not
   old-age pension): £
3. Annuity from life-insurance company or other
   source: £
4. Money left by will or legacy: £
5. Money received from life-insurance company by way
   of loan, bonus, surrender value, or sum assured:
   £
6. Money received as compensation for accident, loss
   of office, or other cause: £
7. Money withdrawn from bank, or obtained by mort-
   gage of property: £
8. Interest on money lent, on mortgage, in bank, or in
   other institution: £
9. Money derived from property (such as rent, or from
   sale of milk, grain, or produce of any kind):
   £
10. Money derived from sale of gold, gum, or other
    natural product: £
11. Allowances or valuable consideration received from
    relatives or other persons: £
12. Estimated value of free board and lodging (not to
    exceed £26): £

[NOTE.—Any amount received by way of sick-allowance
or funeral benefit from any registered friendly society is
exempt by law from being a charge against the pension.]

The names and addresses of the person or persons from whom
the above income was received are as follows: [Item].
The name and address of the person who provided free
board and lodging as above are :

[Registrar to use Form G1 or G2.]

The following interests in landed and house property are
owned by me and by my husband [wife]:—
In my name,—
Freehold: .
Leasehold: .
Life or other interest: .

In name of my husband [wife],—
Freehold: .
Leasehold: .
Life or other interest: .

Section and Block numbers: .
Locality: .
Area: .
Government valuation:
£ .
Total: .

[Registrar to use Form C.]

[NOTE.—Particulars of Native land to be supplied on
separate Form No. 1A.]