JAN. 31.] THE NEW ZEALAND GAZETTE. 401

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

[Registrar to use Form G.]

(2.) That the property owned by me is as follows:—

Value. £

Land and houses [Freehold, leasehold, or other tenure — give block and section numbers] .. .. ..

Money in hand, in bank, or lent out on mortgage .. .. ..

Stock, furniture, shares, or other property [Give description] .. .. ..

My property is mortgaged to—

Name: .

Address: .

The amount of mortgage owing at the present time is £ .

[Registrar to use Form L.]

(3.) That I have not lent or disposed of any money, or sold or transferred any property, during the past year.

(4.) That I have not been left any money or property of any kind during the past year.

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.]

Declared by the said , at , this day of , 19 , before me, declarant fully understanding the contents of the 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 the 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 statements 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 section 8, paragraphs (c), (d), (e), (f), and (i).

(2.) Actual income (section 2, principal Act)
Income under section 14, (b), principal Act)
Income under section 5, 1909 Act

Totals .. £ | |

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

Net property .. £ | |

Notes: .

Decision: .

Date: , 19 . , Stipendiary Magistrate.

[Form 20 (Reg. 40). District.

LIST OF PENSIONERS TO WHOM FORMS OF INCOME AND PROPERTY STATEMENT ARE TO BE POSTED FOR THE INCOME-YEAR ENDING IN THE MONTH OF , 19 .

This form is to be returned to me duly completed.

Date: , 19 . — , Commissioner.

[Form 21 (Reg. 40).

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

CIRCULAR AS TO INCOME AND PROPERTY STATEMENT.

To .

THE year for which your pension-certificate, No. , was granted will shortly expire, and, in order to ascertain whether you are entitled to a pension-certificate for the ensuing year, you must fill up the accompanying income and property statement for the income-year ending on the day of , 19 , and send it to the Registrar of Old-age Pensions at immediately after the close of the said income-year.

The statement must be supplied whether you claim a pension for the ensuing year or not, and it is important that it be declared before either a Registrar, Postmaster, solicitor, Justice of the Peace, or constable.

If the statement is not sent in promptly, you are liable to to lose one or more instalments of pension.

Date: , 19 . — , Commissioner.

[Form 22 (Reg. 45). District: . Pension No. .

Under the Old age Pensions Acts, 1908 and 1909.

MAGISTRATE’S CERTIFICATE AS TO RENEWAL OF PENSION.

To the Registrar for the Old-age Pension District.

I HEREBY certify that I have investigated the Income and Property Statement of [Name, occupation, and address], for the income-year ended the day of , 19 , and am satisfied on the following points:—

(1.) Income (section 2, principal Act)
Income (section 14, (b), principal Act)
Income (section 5, 1909 Act) ..

Totals .. £ | |

· Deduction on account of income in excess of £34 .. .. £

Deduction in terms of section 15, (b) £

[NOTE.—Please indicate if pensioner is single, widowed, or married.]

(2.) 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 pensioner is married, see section 15, (a).]