398
THE NEW ZEALAND GAZETTE.
[No. 9

numbered pension-certificate, hereby apply that the office of
payment may be changed from
to
, on the
grounds that
.
The instalments required at the new paying office are as
follows:

Date:
, 19
.
[Signature of Applicant.]

The Commissioner, Wellington.
For your information. The change has been noted on the
pension-certificate.

, Registrar [or Postmaster].

Date:
,19
.

——
[Form 13 (Reg. 26).]

OLD-AGE PENSION ADVICE.

Instalment due on 1st
.

To the Postmaster of
.

Pension District:
.

Pension-certificate Number:
.

Pay
the sum of
pounds
shillings
and
pence, on production of the pen-
sioner’s certificate.

, Accountant, G.P.O.

I hereby acknowledge the
receipt of the above-named
sum.

[Signature of Pensioner or his Agent.]

Signature of Witness to Mark (if payee unable
to write) or to signature of Maori:
.

• Warrant under section†
  , dated
  ,
  produced.

• To be used only when paid to an Agent.
  † Insert here section 41 or 42 as required.

When the instalment is remitted direct to the pensioner
(or agent) by registered letter, the paying officer will note
hereunder:—

Registered-letter Number:
.

Office of Delivery:
.

[Initials of Paying Officer.]

IMPORTANT.—Payment can only be made to an agent who
has been appointed in the prescribed manner. (See sections
41 and 42 of “The Old-age Pensions Act, 1908,” and the
regulations made thereunder.)
This instalment is payable for a period of one calendar
month only after the due date.

——
[Form 14 (Reg. 33).]

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

APPLICATION FOR PAYMENT OF FORFEITED INSTALMENT.

Pension No.
.
District:
.

I,
, [Address], being the pensioner [or, as the
case may be, the authorised payee], hereby apply for payment
of the forfeited instalment which became due on the 1st day
of
, 19 ; and in support of this application I hereby
declare that the reason why the instalment in question was
not collected is as follows:—

[If the applicant is an agent he shall state whether pen-
sioner is alive, and give address.]

The pension-certificate is attached.

Signature:
.

Witness:
.
Date:
, 19
.

Occupation:
.

Address:
.

The Commissioner of Old-age Pensions, Wellington.
I have examined the pension-certificate, and find that
payment of the instalment applied for is not recorded
thereon.

[Registrar to here state whether he recommends payment,
and give reason.]

, Registrar [or Postmaster] at
.

[NOTE.—No application for an instalment which has been
forfeited three months will be entertained unless under
exceptional circumstances.]

[Form 15 (Reg. 36).]

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

APPLICATION FOR PAYMENT OF AMOUNT ACCRUED TO DATE OF
DEATH.

Pension No.
.
District:
.

Name of pensioner:
.

I,
, [Address], do hereby apply for payment of the
amount accrued to date of death of the above pensioner, who
died on the
day of
, 19
, at
.

Receipt for £
for burial expenses, which have been
paid by me, is attached. The pension-certificate is also for-
warded herewith.

Please make amount payable at
Post-office.

[Signature of Applicant.]

Date:
, 19
.

If the applicant is a relative the degree of relationship to
be stated.

[NOTE.—Every application made on behalf of a charitable
institution must be accompanied by a warrant under
section 41.]

The Commissioner, Wellington.
This pensioner died in such circumstances that no money
was left in his estate whereby the burial expenses [or, as the
case may be, cost of maintenance] could be paid, and I
recommend payment being made to the applicant, who de-
frayed the same.

, Registrar at
.

Date:
,19
.

[NOTE.—No application for accrued amount will be enter-
tained after three months have elapsed since date of death
unless under exceptional circumstances, which must be
explained.]

——
[Form 16 (Reg. 37).]

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

APPLICATION FOR WARRANT UNDER SECTION 41.

Notes.

No payment will be made under this warrant in respect of a
deceased pensioner unless the special authority of the Com-
missioner has first been obtained.
A separate warrant is required for each institution controlled
by any governing body.

On behalf of [Name of the Charitable Aid or Hospital
Board, or other charitable society], I,
, Secretary [or
Treasurer] of the said body, hereby make application for
a warrant authorising the payment to it of the instalments
of pension as specified in the following Schedule, the pen-
sioner in each case having been maintained in the [Name
of institution].

Schedule.

| Name of Pen-
sioner. | No. of Pension-
certificate. | Due Date of Instal-
ment. | Amount of Instal-
ment. | Cost of Mainten-
ance or Relief. | Period of Mainten-
ance or Relief. (Supply dates.) |
|--- | --- | --- | --- | --- | ---|
| | | | £ s. d. | £ s. d. | |
| | | | | | |
| | | Total £ | | | |

And, in support of this application, I hereby solemnly and
sincerely declare that the said governing body has, in the
case of each pensioner, maintained or given relief to him for
the period set forth opposite his name in the foregoing
Schedule, and the reasonable cost thereof is as therein men-
tioned [or, as the case may be, has defrayed the cost of
burial].

And I make this solemn declaration conscientiously be-
lieving 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.”

, Applicant.

Declared by the said
, at
, this
day
of
, 19
, before me—

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