3504 THE NEW ZEALAND GAZETTE. [No. 97

The following property, owned by me or my children, has
been transferred or sold during the past twelve months :—

The money received by me for transfer of above property
has been disposed of as follows :
In addition to property now owned or transferred as shown
in the foregoing statement, money or other valuable con-
sideration has been received and disposed of by me or my
children under fourteen during the past twelve months
as follows :—

In the event of a pension being granted to me, I desire :—

1. That instalments be made payable at the post-office
   at
   [NOTE.—Payment can be arranged at any post-office which is not a
   money-order office by registered letter.]
2. That, on account of my physical inability to attend the
   above post-office, instalments be made payable for the benefit
   of myself and children to—
   Full name :
   Occupation and address :

I do hereby solemnly and sincerely declare that the contents
of this my claim are true and correct in every particular,
and that to the best of my knowledge and belief I have ful-
filled all the requirements and am exempt from all the dis-
qualifications under the aforesaid Act up to the date of this
my claim, and am entitled to a pension. 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 applicant.]
Declared by the said , at , this day
of , 19 , before me, the declarant fully under-
standing the contents of this claim—
, Justice of the Peace [or Solicitor, or Registrar of
Pensions, or Postmaster, or Constable].

This is to certify that the contents of this claim have been
read over and fully explained to the applicant, who appeared
to fully understand the meaning thereof.
, Postmaster [or Clerk of Court, or Constable, or
Registrar of Pensions].
[Date.]

Magistrate's Notes.
I have investigated the application herein, and find the
following facts proved :—

1. Applicant is a widow.
2. Applicant is a British subject.
3. Applicant has children who are under fourteen
   years of age.
4. Applicant has been resident in New Zealand for six
   months.
5. Applicant has not transferred property to qualify for
   the pension.
6. Applicant is of sober habits and of good moral character.
7. The income of applicant and such of her children as are
   under fourteen is as follows :—
   £ £
   (a.) Personal earnings .. .. .. .. £ ..
   Less exemption .. .. .. .. 100 ..
   (b.) Actual income from property .. .. ..
   (c.) Actual income from all other
   sources .. .. .. .. .. ..
   (d.) Constructive income in terms of
   section 8 (2) : Home, £ ; fur-
   niture and effects, £ (less mort-
   gage, ) .. .. .. .. ..
   Cash .. .. .. .. .. .. ..
   All other property .. .. .. ..
   Less mortgage .. .. .. ..
   Total .. .. .. .. .. ..
   5 per cent. .. .. .. .. .. ..
   Total income .. .. .. £
   Notes :
   Decision :
   Date : , 191 .
   , Stipendiary Magistrate.

[Form 2 (Widows—8).
Claim No. District :
Pension No.
Under the Widows’ Pensions Act, 1911.
MAGISTRATE'S CERTIFICATE OF ESTABLISHMENT.

I HEREBY certify that the above-numbered claim, made by
, [Occupation ; if no present occupation, state former
occupation], of , has this day been investigated by
me, and it has been proved to my satisfaction,—

1. That the applicant fulfils the conditions of the aforesaid
   Act.
2. That the applicant is the mother of child[ren]
   under the age of fourteen years, and is entitled to a
   maximum pension of £ , subject to the
   deduction shown hereunder.
3. That the applicant's income from all sources is as
   follows :—

Deduction on account of income in excess of £30
Decision : The applicant is granted a pension of £

The pension-year commences on the 1st day of ,
191 .
[Date.]
, Magistrate.
* Particulars of other property.

Payment is desired at the Post-office.
Warrant under section 18 is required on account of
in favour of [Full name, occupation, and address].
Noted in Claim Register and in Pension Register : [Initials
of Registrar].

[Form 3 (Widows—9).
The pension being for the personal support of the pensioner, this certi-
ficate is absolutely inalienable whether by way of assignment, charge,
execution, bankruptcy, or otherwise howsoever.

(Not transferable.)
District : Certificate No.
Dominion of New Zealand.
Under the Widows’ Pensions Act, 1911.
PENSION CERTIFICATE.

Specimen of Signature of Pensioner :
THIS is to certify that has been granted a
pension of pounds sterling, payable by twelve
equal monthly instalments of £ : : , of
which the first instalment is payable on the 1st day of
, 191 , and each subsequent instalment on
the first day of each calendar month thereafter, at the
post-office at
Countersigned :
[Date.] D. ROBERTSON, Commissioner.

CAUTION.—Instalments of pension are payable for a period of one
calendar month after due date, and should be collected during that
month.