JAN. 31.] THE NEW ZEALAND GAZETTE. 399

Warrant under Section 41.

Warrant is hereby granted for the total sum of £ , on the condition that any surplus of pension after defraying cost of maintenance is handed to the pensioner.

, Registrar of the Old-age Pension District.
Date: , 19 ,
[To be retained by the Postmaster, and forwarded with his accounts.]

[Form 17 (Reg. 38).]
Pension No.
District:
The Old-age Pensions Acts, 1908 and 1909.
APPLICATION FOR WARRANT UNDER SECTION 42.

Notes for Registrars.

Pensioners who do not find it convenient to draw their instalments at the nearest money-order office may, on making application on Form 12, arrange to receive their instalments in person at the nearest post-office by registered letter.

Pensioners may, by making application on Form 12, arrange to draw their instalments in person temporarily at any post-office in New Zealand. This does away with the necessity of a complete transfer of the pension or the issue of a warrant.

No warrant under section 42 will be issued on behalf of a pensioner who is being maintained in or receiving relief from a hospital or charitable institution, unless the application is accompanied by a certificate from the authorities of the institution that they have no claim against the pensioner for maintenance or relief.

Name of Pensioner:

I HEREBY apply for a warrant under section 42 directing that until same is cancelled or expires all instalments of the pension payable pursuant to pension-certificate No. shall be paid to. [Full name, occupation, and address], for the sole benefit of the pensioner, on the grounds that [Briefly state grounds].

Please receive pension-certificate herewith.
Signature:
Date: , 19 .
Witness:
Occupation:
Address:

I consent hereto.

, Proposed Payee.

The Commissioner, Wellington.

I recommend issue of warrant in this case. The pension-certificate is attached.

Date: , 19 .

Head Office Notings.

Warrant and pension-certificate issued to , 19 .
Examined and despatched: File:

[Form 18 (Reg. 38).]
Under the Old-age Pensions Acts, 1908 and 1909.
WARRANT UNDER SECTION 42.
Pension-certificate No. District:

Name of Pensioner:

I HEREBY direct that all instalments of pensions payable pursuant to the above-mentioned pension-certificate shall, on presentation of the said certificate, be payable to [Full name, occupation, and address] for the benefit of the pensioner.

This warrant expires with payment of the instalment due on the 1st , 19 .

Commissioner.
Countersigned:
Date: , 19 .

It is not lawful for an agent appointed under this warrant to collect an instalment of pension after the death of the pensioner, or while the pensioner is not residing in New Zealand.

[Form 19.(Reg. 39).]
Claim No. Previous Pension: £
Pension-certificate No.

Under the Old-age Pensions Acts, 1908 and 1909.
INCOME AND PROPERTY STATEMENT

For the Income-year ended the day of , 19

I, THE undersigned, hereby make claim for a renewal of my pension under the aforesaid Acts, to be made payable at the Post-office, and in support thereof do hereby solemnly and sincerely declare as follows:-

My full name is
My full address is
My occupation is

The full name, address, occupation, and amount of pension of my husband [wife] are,-

Name:
Address:
Occupation:
Amount of husband's [wife's] pension: £

For the year ended as above my total income was as follows:- £ s. d.
Money derived from property owned by me (such as rent, interest from money, &c.) ..
Money derived from sale of gum, gold, milk,
grain, or other produce
Wages or other personal earnings
Money left by will or legacy
Insurance-money received
Annuity or pension of any kind
Money received from relatives or any other source
Estimated cost of free board and lodgings

Total.. £

The names and addresses of the persons from whom I earned or received money are

[Registrar to use Form G1 or G2.]

For the year ended as above the total income of my husband [wife] was,- £ s. d.
Money derived from property owned (such as rent, interest from money, &c.)
Money derived from sale of gum, gold, milk, grain, or other produce
Wages or other personal earnings
Money left by will or legacy
Insurance-money received
Annuity or pension of any kind
Money received from relatives or any other source
Estimated cost of free board and lodgings

Total.. £

The names and addresses of the persons from whom my husband [wife] earned or received money are

[Registrar to use Form G1 or G2.]

The property owned by me is as follows:- Value.
Land and houses (freehold, leasehold, or other tenure) £
Money in hand, in bank, or lent out on mortgage
Stock, furniture, shares, &c.

My property is mortgaged to--

Name:
Address:

The amount owing on this mortgage at the present time is £

[Registrar to use Form L.]

The property owned by my husband [wife] is as follows:- Value.
Land and houses (freehold, leasehold, or other tenure) £
Money in hand, in bank, or lent out on mortgage
Stock, furniture, shares, &c.

My husband's [wife's] property is mortgaged to--

Name:
Address: