3028
THE NEW ZEALAND GAZETTE.
[No. 101

I have served in the New Zealand Forces as follows:—
Unit in which served:
Rank: . Regimental No. .
Date of departure from New Zealand [State with which Force]: .
Date of termination of appointment or of discharge [To be produced]: .
State nature of disablement: .
State cause of disablement: .
State when and where wound or injury received or disease contracted [Date]: . [Place] .
What were your average earnings before you became a member of the Forces? .
What are your average earnings now? .
Do you receive, or are you entitled to receive, any payment of public moneys by way of compensation, civil or military pension, or gratuity under any New Zealand or Imperial Act? If so, please supply particulars: .
I was married at on the day of , 1 .
My wife’s full name is .
State if wife alive and living with you: .

The following particulars relate to such of my children as are under sixteen years of age and are dependent upon me for their support:—

The following particulars relate to others who were wholly or in part dependent upon my earnings at any time during the twelve months preceding the date on which I became a member of the Forces:—

• State whether father, mother, grandfather, grandmother, stepfather, stepmother, grandchild, brother, sister, half-brother, half-sister, or mother-in-law.

The name and address of a person (who must be a civilian, well known, and not a relative) who can identify me as a member of the Forces are as follows: .
Do you employ a personal attendant other than a member of your family? .
If so, what is the nature of the services rendered? .
What means have you to meet the cost of such attendant? .

I 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 am entitled to a pension under the War Pensions Act, 1915.

[Signature of Applicant.]

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

War Pensions—2.
(This form is to be issued only to or on behalf of a bona fide applicant for pension.)

Local Claim No. . H.O. No. .

Under the War Pensions Act, 1915.

WAR PENSION-CLAIM.
(For dependant only.)

To the Registrar of Pensions at .

I, THE undersigned, do hereby apply for a pension under the above Act.
My full name is .
My occupation and address are .
If pension is granted, payment is desired at the post-office at .
I was born in [Country only] . Present age: .

I am the [State whether wife, father, mother, grandfather, grandmother, stepfather, stepmother, brother, sister, half-brother, half-sister, mother-in-law, or guardian of child or grandchild] of , a member of the New Zealand Expeditionary or Naval Forces, who died [or was reported missing] at on the day of , 191 [or who is wholly or partially disabled on account of ].
What proof have you of relationship [Please submit it]? . .
If applicant is wife or widow of Native member of Forces, and married in accordance with Native custom, supply name of Judge, Commissioner, or Registrar of Native Land Court who can certify to that effect: .
State to what extent the said member contributed to your maintenance during the twelve months preceding the date on which he joined the Forces: .
Are you living with the said member (if alive)? .

The following particulars relate to the service of the said member of the Forces:—
Rank: . Regimental No. .
Date of departure from New Zealand [State with which Force]: .
Date of termination of appointment or of discharge [To be produced]: .

The following particulars relate to the children (or grandchildren) under sixteen years of age who were dependent upon the said member and are now dependent upon me for their support [To be filled in only when applicant is guardian of children under sixteen years]:—

The income of myself, and of my husband [wife], and of the aforesaid children under sixteen during the past twelve months has been as follows:—

The names and addresses of the persons from whom above income was received are as follows: .