Jan. 31.] THE NEW ZEALAND GAZETTE. 391

6. Property (other than home and furniture)
   Less mortgage .. ..
   Net property .. £

Applicant.

Husband. [Wife.]

Notes:
Decision: , Stipendiary Magistrate.
Date: , 19 .

[Form 1A (Reg. 13).]
[This form is to be supplied by every Native applicant.]
Under the Old-age Pensions Acts, 1908 and 1909.
STATEMENT TO BE FURNISHED IN REGARD TO NATIVE LAND.
Claim No. District.
Full name of applicant: [Give all names known by].
Address:
Name of tribe or hapu:
PARTICULARS of Native land in respect of which I claim or possess any customary rights or any interest are as follows:—

Names and Localities of Blocks.

Nature and Extent of my Share or Interest therein.

Name under which I appear in the List of Owners, and whether as Original Owner or by Succession.

My land is leased to Mr. [Name, occupation, and address], who pays me a yearly rental of £

Land previously held by me.
Names and localities of blocks:
Nature and extent of share or interest previously held by me:
Name under which I held such share or interest:
How disposed of (whether by sale, gift, or otherwise):
When disposed of, and amount of consideration:
Names and addresses of persons to whom sold or otherwise disposed of:

Full name of my husband [wife]: [Give all names known by].
Address:
Name of tribe or hapu:
PARTICULARS of Native land in respect of which my husband [wife] claims or possesses any customary rights or any interest are as follows:—

Names and Localities of Blocks.

Nature and Extent of Share or Interest therein.

Name under which my Husband [Wife] appears in the List of Owners, and whether as Original Owner or by Succession.

My husband’s [wife’s] land is leased to Mr. [Name, occupation, and address], who pays therefor a yearly rental of £

Land previously held by my Husband [Wife].
Names and localities of blocks:
Nature and extent of share or interest previously held by my husband [wife]:
Name under which my husband [wife] held such share or interest:
How disposed of (whether by sale, gift, or otherwise):
When disposed of, and amount of consideration:

B

Names and addresses of persons to whom sold or otherwise disposed of:
This statement relates to my pension-claim [or, as the case may be, my income and property statement] bearing this day’s date.
Dated at , this day of , 19 .
[Signature of applicant.]
This is to certify that the contents of this statement were fully explained to and appeared to be fully understood by the applicant.
[Signature.]
Date: , 19 .
[Official designation.]

[Form 1B (Reg. 15).]
Pension-claim No. District.
Under the Old-age Pensions Acts, 1908 and 1909.
APPLICATION TO TRANSFER PROPERTY TO THE PUBLIC TRUSTEE.
I, THE undersigned, [Occupation, address], having duly made application for a pension [or renewal of pension], and being desirous of availing myself of the provisions of section 11 of the principal Act as amended by section 5 of the Amendment Act, do hereby apply to convey or transfer to the Public Trustee the freehold property on which I am residing, and which is unencumbered, in order that the capital value of the said property may be deducted from the capital value of all the accumulated property owned by me. In token of my application, I do hereby deliver up the deeds of the said property, the description, area, and value of which is as follows:—
Description:
Area and Government valuation:
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.]
Witness—[Name, address, and occupation].
Date: , 19 .

The Commissioner, Wellington.
Herewith please receive the deeds of the above-mentioned property. As far as can be ascertained by the inquiry forms, and making allowance for the transfer of this property, the applicant is qualified to receive an old-age pension.
Date: , 19 . , Registrar at .

The Public Trustee, Wellington.
I certify that the following is a copy of the entry in the general valuation roll in regard to the aforesaid property, the deeds of which are herewith forwarded for your inspection:—
Local district or borough:
Number of section, allotment, block, street, or particular locality:
Area:
Value of property under “The Government Valuation of Land Act, 1908”:
, Commissioner, Old-age Pensions.
Date: , 19 .

The Commissioner, Old-age Pensions.
I am prepared to accept the deeds of the above mentioned property as security for the payment of such pension as, but for the transfer of the said property, would not otherwise be payable. I am retaining the deeds meanwhile.
Date: , 19 . , Public Trustee.
[Pension No. .

Magistrate’s Certificate.
To the Registrar for the Old-age Pension District.
I hereby certify that the application for pension made by [Name, occupation, and address], has this day been investigated by me, and the following facts have been proved before me:—

1. The applicant has fulfilled the conditions set out in “The Old-age Pensions Act, 1908,” section 8, paragraphs (a), (b), (c), (d), (e), (f), and (i), and the amendment thereto.