396
THE NEW ZEALAND GAZETTE.
[No. 9

tion notice, bank-book, or other document), or any papers
showing how such property has been dealt with.
Good and sufficient reasons will require to be given for
your non-attendance on the date mentioned herein; other-
wise your application is liable to be refused.

Date: , 19 .
, Clerk of Court at

[Form 4 (Reg. 8).

Under the Old-age Pensions Acts, 1908 and 1909.
NOTICE OF MAGISTRATE’S DECISION.

To
I HAVE to inform you that your application for an old-age
pension [or renewal of pension No. ] under the above
Acts has been investigated by the Magistrate, whose decision
is as follows:—

• Application granted for £ . Pension-certificate will
  reach you in due course.
• Application adjourned on account of .
• Application refused on account of .

Registrar of the Old-age Pension District.
Date: , 19 .
*Delete where necessary, and if adjourned or refused give
reasons.

[Form 5 (Reg. 9).

Under the Old-age Pensions Acts, 1908 and 1909.
MEMORANDUM OF REJECTION OR ADJOURNMENT.

To the Registrar, Old-age Pension District.
Pension-claim No. , made by .
I HEREBY certify that the above-numbered claim has this
day been investigated by me, and my decision is that it is
rejected [adjourned] on the following grounds:—

The following material points have been proved:—

Dated at , this day of , 19 .
, Stipendiary Magistrate.

Noted in Pension-claim Register, and forwarded to the
Commissioner at Wellington.—[Initials of Registrar.]

Head Office Notings.
Claim reg.: . Claim card: . File: .

[Form 6 (Reg. 10).

Pension-claim No. . Pension-certificate No. .
Under the Old-age Pensions Acts, 1908 and 1909.
MAGISTRATE’S CERTIFICATE OF ESTABLISHMENT OF CLAIM.
To the Registrar for the Old-age Pension District.
I HEREBY certify that the above-numbered pension-claim,
made by [Name, occupation, and address. If no present
occupation, state former occupation] has this day been in-
vestigated by me, and the following facts have been proved
before me:—

1. Age. By [State briefly the nature of the proof].
2. The claimant has fulfilled the conditions set out in
   “The Old-age Pensions Act, 1908,” section 8, para-
   graphs (a), (b), (c), (d), (e), (f), and (i), and the amend-
   ment thereto. (See indorsement at back hereof.)

—
| | Applicant. | Husband. [Wife.] |
|---|---|---|
3. Income (section 2, principal Act)
Income (section 14, (b), principal Act)
Income (section 5, 1909 Act) ..
Totals .. £

Exemption in terms of section 6, 1908 Act .. £
£ £
Deduction on account of income in
excess of £34 .. .. ..
Deduction in terms of section 15, (b)

—
| | Applicant. | Husband. [Wife.] |
|---|---|---|
4. Property (other than home and furniture)
Less mortgage at present date £
Total net property £

[State in margin particulars of property.]
Total net property of husband and wife .. £

Deduction on account of property,
being £1 for every £10 in net
value .. .. .. £
[NOTE.—If claimant is married, see section 15, (a).]

Decision.—For the twelve months commencing on the
first day of the current month, the claimant is hereby
granted a pension of £ ( pounds).
Dated at , this day of , 19 .
, Magistrate.

Noted in Pension-claim Register and Old-age Pension
Register.—[Initials of Registrar.]

Particulars to be supplied by Registrar.
Date of birth: . Nationality: [If pensioner is
a naturalised subject, supply date of naturalisation].
Name of husband [wife]: [If not married, state conjugal
condition and sex].
Husband’s [wife’s] pension No. . Paying office: .
Pension-certificate , issued to , : : ,
19 .

[Form 7 (Reg. 19).

DISTRICT OLD-AGE PENSION REGISTER.
Pension-certificate No. .
Name in full: . Husband’s [or
wife’s] pension
Address: . No. .
Occupation: .
District: .

—
District: .
[Form 8 (Reg. 20).
Pension No. .

Under the Old-age Pensions Acts, 1908 and 1909.
ADVICE OF ENTRY IN PENSION REGISTER.

Name of Pensioner: .
To the Commissioner of Old-age Pensions, Wellington.
I HAVE to advise you that the following entry in connec-
tion with the above-mentioned pension-certificate has this
day been made by me in the Pension Register:—

[Important.—Please give full particulars relating to the
entry, including, where necessary, the due date of the first
instalment affected.]

Date: , 19 .
, Registrar.