890
THE NEW ZEALAND GAZETTE.
[No. 9

My property as above is mortgaged to [Give full name, address, and occupation of mortgagee].
The amount owing by me on this mortgage at the present time is £

The property of my husband [wife] is mortgaged to [Give full name, address, and occupation of mortgagee].
The amount owing by my husband [wife] on this mortgage at the present time is £

[Registrar to use Form I.]

State what part of property above mentioned is used as a home.

The value of my furniture and personal effects is (if insured, give insured value) £

The value of my husband’s [wife’s] furniture and personal effects is (if insured, give insured value) £

Money owned by me and by my husband [wife] is as follows:—

In my name and in the name of my husband [wife],—
In Post-Office Savings-Bank :
In Bank of New Zealand :
In Bank of New South Wales :
In Bank of Australasia :
In Union Bank of Australia :
In National Bank of New Zealand :
In any other bank or institution :
In any building society :

Amount in bank:
[If account closed, give date closed.]
Town where account kept, and number of pass-book :
Total :

[Registrar to use Form B or D.]

Other property owned by me and by my husband [wife] is as follows:—

Owned by me or by my husband [wife],—
Cash in hand :
Money in hands of or lent out on mortgage to [Give name and address].
Live-stock (such as sheep, cattle, horses, &c.) :
Mining shares, debentures, bonds, or shares in any company, institution, building or other society : [Particulars].
Interest in business, stock-in-trade, or venture of any kind :
Other property : [Give description].
Totals :

Give particulars of bill of sale or mortgage on any of this property.

If any of this property is insured, state which, and give amount of insurance.

The following property has been transferred or sold by me or by my husband [wife] since the 1st November, 1898 :—
Transferred by me. Transferred by my husband [wife],—
Freehold :
Leasehold :
Cash or money on mortgage :
Live-stock :
Shares, debentures, &c. :
Furniture, &c. :
Interest in business :
Life or other interest in real or other property :

Description :
Name and address of person to whom transferred or sold :
Date of transfer or sale :
Amount received for transfer or sale :

The money received by me for the transfer or sale of property above has been disposed of as follows :

The money received by my husband [wife] for the transfer or sale of property above has been disposed of as follows :

In addition to the property now owned, or transferred, or sold by me or by my husband [wife], as shown in the foregoing statements, money or other valuable consideration has been received or disposed of since the 1st November, 1898, as follows:—
By myself : [Give particulars, and how disposed of].
By my husband [wife] : [Give particulars, and how disposed of].

In the event of a pension being granted to me, I desire—

1. That instalments be made payable at the Post-office at

[NOTE.—Payment can be arranged at any post-office not a money-order office by registered letter.]

2. That, on account of my physical inability to attend the above post-office, instalments be made payable for my benefit to [Full name, occupation, and address].

[Form 17 to be supplied.]

I do hereby solemnly and sincerely declare that the contents of this my claim are true and correct in every particular, and 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 up to the date of this my claim, and am entitled to a pension.

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, 1908.”

[Signature of applicant.]

Declared by the said , at , this day of , 19 , before me, declarant fully understanding the contents of this claim.

Justice of the Peace [or Solicitor, Registrar of Old-age Pensions, Postmaster, Constable].

This is to certify that the contents of this claim have been read over and fully explained to the applicant, who appeared to fully understand the meaning thereof.

[Signature of official—Clerk of Court, or Constable, or Postmaster, or Registrar.]

[Not to filled in by the applicant.]

To , Esq., Stipendiary Magistrate.

The contents of this claim have been read over to the applicant. As far as I have been able, I have verified the statements of the applicant by the inquiry forms attached, précis of the replies being as follows:—

, Registrar at
Date : , 19 .

Magistrate’s Notes.

I have investigated the within claim for old-age pension, and find the following points proved:—

1. Age to be years.
2. Continuous residence to be years.
3. Applicant is not disqualified under section 8, paragraphs (c), (d), (e), or (i).
4. Applicant fulfils [or does not fulfil] the conditions of section 8, paragraph (f).