Nov. 23.] THE NEW ZEALAND GAZETTE. 3505

[Form 4 (Widows—12).]

APPLICATION FOR CHANGE OF OFFICE OF PAYMENT.

[NOTE.—Payment can be made at any post-office in New Zealand not
a money-order office by registered letter.]

Pension-certificate No. District :

I, , [Address], being the pensioner [or, as the case may
be, the duly authorized agent] pursuant to the above-num-
bered pension-certificate, hereby apply that the office of pay-
ment may be changed from to , on the
grounds that

The instalments required at the new paying office are as
follows :—

[Signature of applicant.]

[Date.]

TO BE FORWARDED THROUGH REGISTRAR IN EVERY CASE.

THE COMMISSIONER, WELLINGTON.

For your information. The change has been noted in my
Widows’ Pension Register, and the pension-certificate has
been altered.

, Registrar at

[Form 5 (Widows—18).]

To be surrendered on payment of the instalment due 1st
, 19 .

District :

Pension-certificate No.

WARRANT UNDER SECTION 18.

I HEREBY direct that the instalments of pension payable
pursuant to the attached pension-certificate shall be payable
for the benefit of the pensioner and her children to [Full
name, occupation, and address].

Countersigned :

[Date.]

D. ROBERTSON, Commissioner.

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

[Form 6 (Widows—19).]

Claim No. . Previous Pension : £ . Pension No. .

Under the Widows’ Pensions Act, 1911.

APPLICATION FOR RENEWED PENSION-CERTIFICATE.

To the Registrar of Pensions at

I, THE undersigned, hereby make claim for a renewal of my
pension under the aforesaid Act, to be made payable at the
Post-office.

My full name is

My full address is

The names of my children who are still under the age of
fourteen years are :

It is my wish that instalments of my pension shall continue
to be drawn by [Name, occupation, and address].

For the twelve months ended the 1st day of , 191 ,
the income of myself and of such of my children as are under
the age of fourteen years has been as follows :—

£

1. Salary, wages, or other personal earnings ..
2. Profits from business .. ..
3. Superannuation or other pension .. ..
4. Annuity from life assurance company or other
   source .. .. ..
5. Money left by will or legacy .. ..
6. Dividends from shares, debentures, or invest-
   ments of any kind .. ..
7. Money from life assurance company, such as loan,
   bonus, surrender value, or sum assured ..
8. Money received as compensation for accident,
   loss of office, or other cause .. ..
9. Interest on money lent on mortgage, in bank, or
   other institution.. .. ..
10. Money derived by way of rent from property .. ..
11. Money derived from sale of milk, grain, or pro-
    duce of any kind .. ..
12. Money withdrawn from bank or obtained by
    mortgage on property .. ..
13. Allowances or valuable consideration received
    from relatives or other persons .. ..
14. Estimated value of free board and lodging ..

Total .. .. .. £

Actual date of receipt of income exceeding £60 (other than
personal earnings) was

Names and addresses of persons from whom above income
was received :—

[Registrar to issue Forms G1 or G2.]

Property owned by me and by my children under fourteen
years of age is as follows :—

———

Land and house property (used as a home)
Furniture and personal effects [If insured,
give insured value]
Land and house property (not used as a
home)
Money in hand, in bank, or lent out ..
Live-stock, shares, or other property [Give
particulars] :—

Totals .. .. ..

The above property is mortgaged to [Give full name, address,
and occupation of mortgagee] :—

Amount owing on said mortgage at the present time is—On
home and furniture, £ ; on other property, £ .

[Registrar to issue Form 1.]

Property sold or transferred by me during the past year is
as follows :—

Any other property [Particu-
lars] : | |

The money received by me for transfer of property above
has been disposed of as follows :—

In support of my application 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 Act.

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.

[Signature of Pensioner.]

Declared by the said , at , this day
of , 191 , before me— , Justice of the Peace
[or Solicitor, or Registrar of Pensions, or Postmaster, or
Constable].

Magistrate’s Notes.

I have investigated the application herein, and find the
following facts proved :—

1. Applicant is still a widow.

2. Applicant has children under fourteen years of
   age.

3. Applicant has not transferred property to qualify for
   the pension.

4. Applicant is of sober habits and of good moral character.

5. The income of applicant and such of her children as are
   under fourteen is as follows :—
   (a.) Personal earnings £ , Pension £
   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, £ ; furniture and
   effects, £ .. £
   Less mortgage .. £

    Cash             ..             ..
    All other property .. £
    Less mortgage             .. £
   
    Total             ..             ——
    Five per cent. ..             ..
   
    Total income ..             ..             .. £

Notes :
Decision :
Date : , 191 . , Stipendiary Magistrate.