400

THE NEW ZEALAND GAZETTE.

[No. 9

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

[Registrar to use Form L.]

[Please answer questions hereunder, and give particulars.]

Do you permanently reside on any part of your
own property above stated?

Do you permanently reside on any part of your
husband's [wife's] property above ?

What income does the property you reside on
produce?

What money have you withdrawn from any bank or other
institution during the past year?

What money has your husband [wife] withdrawn from any
bank or other institution during the past year?

What money have you lent or transferred during the past
year?

What money has your husband [wife] lent or transferred
during the past year?

What property have you transferred or sold during the past
year?

What property has your husband [wife] transferred or sold
during the past year?

Have you been left any money or property of any kind
during the past year? [Give particulars.]

Has your husband [wife] been left any money or property
of any kind during the past year? [Give particulars.]

I solemnly and sincerely declare as follows:-

(1.) That the contents of this my application for renewal
of pension are correct in every detail.

(2.) 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.

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 Pensioner. ]

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

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

To the Registrar for the Old-age Pension District.

[Not to be filled in by Applicant.]

To , Esq., Stipendiary Magistrate.

I hereby certify that, as far as I have been able to do so
with the forms at my disposal, I have verified the state-
ments herein; and, having ascertained that the requirements
of section 8 of the principal Act have [Insert not, as required]
been complied with, I recommend that a pension be granted
for the sum of £ , being the full amount of pension
reduced by £ for property and £ for income
[or, as the case may be, that no pension be granted on account
of ].

, Registrar at .

Date : , 19 .

Magistrate's Notes.

I have investigated the application herein for renewal of
pension, and find the following points proved:-

(1.) The applicant is not disqualified under sec-
tion 8, paragraphs (c), (d), (e), (f), and (i).

Applicant. Husband.
[Wife.]

(2.) Actual income (section 2, prin-
cipal Act)
Income under section 14, (b), prin-
cipal Act
Income under section 5, 1909 Act
Totals

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

Notes:
Decisions:

, Stipendiary Magistrate.

Date : , 19 .

[Form 19A (Reg. 49).]

Claim No. Previous Pension : £
Pension 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 the
pension under the aforesaid Acts granted to , who is
at the present time an inmate of the Mental Hos-
pital.

Payment of the pension is desired at the Post-
office.

, Medical Superintendent.

Date : , 19 .

In the matter of the above application, I hereby certify that
the property owned by the above-named inmate of the
Mental Hospital, who, I understand, is still
alive, is as follows:-

Land and houses [Freehold, leasehold, or other Value.
tenure - quote block and section numbers] £
Money in hand, in bank, or lent out on mortgage
Stock, furniture, shares, or other property [Give
description]
Total £

The property is mortgaged to-
Name:
Address:
The amount of mortgage owing at the present time is £

I hereby further certify that for the year ended as above the
total income of the pensioner was as follows:-

£ s. d.

Money derived from property owned ..
Wages or other personal earnings ..
Money left by will or legacy ...
Insurance-money received ...
Money received from relatives or any other
source ... ....
Total £

Date : , 19 .

, Public Trustee.

[To be filled in if the Pensioner is married.]

In the matter of the application herein for the renewal of the
pension granted to , who is at present an inmate
of the Mental Hospital, I,
, wife [husband]
of the said , do hereby solemnly and sincerely
declare as follows:-

(1.) That for the year ended as stated herein my total in-
come was,-

£ s. d.

Money derived from property owned by me

Money withdrawn from bank or other
institution ..
Wages or other personal earnings
Money left by will or legacy
Insurance-money received
Money received from relatives or any other
source
Estimated cost of free board and lodgings
Total