492
THE NEW ZEALAND GAZETTE.
[No. 9

In Name of my Wife.

In Post-office Savings-bank ..
. Bank of New Zealand ..
. Bank of New South Wales ..
. Bank of Australasia ..
. Union Bank of Australia ..
. National Bank of New Zealand ..
. Any other institution ..
. Any building society ..

Totals .. ..

Other property owned by me and by my wife is as follows:—

Totals .. .. £

Give particulars of bill of sale or mortgage on any of this property :
If any of this property is insured, state which, and give amount of insurance :

The following property has been transferred or sold by me, or by my wife, since the 1st January, 1912:—

The money received by me for transfer of property above has been disposed of as follows :
The money received by my wife for transfer of property above has been disposed of as follows :
In addition to property now owned or transferred, as shown in the foregoing statement, property as under has been received and disposed of since the 1st of January, 1912, as follows:—
By myself [Particulars] : .
By my wife [Particulars] : .

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 fulfilled all the requirements and am exempt from all the disqualifications 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 , 191 , before me, the declarant fully understanding the contents of this claim.

[Justice of the Peace, Solicitor, Postmaster, Constable, or Examining Officer].

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, and has produced his New Zealand War Medal in support thereof.

A Commissioned Officer of the New Zealand Defence Forces [or An Examining Officer under Military Pensions Act, 1912].

Date: , 191 .

[Form 2.
[To be issued only to the holders of pension-certificates issued under the Old-age Pensions Act, or the Military Pensions Act, 1911.]

MILITARY PENSION-CLAIM.

No. .

I, THE undersigned, hereby make claim for a pension under the Military Pensions Act, 1912, and do hereby surrender the certificate issued to me in terms of the Old-age Pensions Act, 1908 [or the Military Pensions Act, 1911].

My full name is :
My full address is :
I desire payment made at the post-office at .
I have served under the Crown in the Maori Wars as follows:—
Corps in which served : .
Rank : . Regimental No. (if any) : .
Period of service [State actual years] : .
Names or localities of actions at which under fire : .
I was awarded the New Zealand War Medal in the year . [Produce New Zealand War Medal; if not in possession of same, state why.]
Give name and address of person of repute (for preference a comrade in arms or other veteran) who is able to identify you as the person to whom a New Zealand War Medal was awarded : .
State alteration (if any) in your circumstances since the old-age or military pension held by you was granted : .

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 fulfilled all the requirements and am exempt from all the disqualifications 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 , 191 , before me, the declarant fully understanding the contents of this claim.

[Justice of the Peace, Solicitor, Examining Officer, 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, and has produced his New Zealand War Medal in support thereof.

A Commissioned Officer of the New Zealand Defence Forces [or An Examining Officer under Military Pensions Act, 1912].

Date: , 191 .

[Form 3.
[To be surrendered on payment of the instalment due 1st , 191 .]

Military pension-certificate No. .
Name : .

WARRANT UNDER SECTION 14.

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

Countersigned : .
Date : .

Commissioner of Military Pensions.

CAUTION.—It is not lawful for an agent appointed under this warrant to collect an instalment after the death of the pensioner, or while the pensioner is in prison, or an inmate of a mental hospital, or not residing in New Zealand.

J. F. ANDREWS,
Clerk of the Executive Council.