New Zealand Gazette – 1927 – No. 16

Page 661

✨ Family Allowances Application Form



Mar. 17.] THE NEW ZEALAND GAZETTE. 661

Income of Myself, Wife, and Children under Fifteen during the Twelve Months preceding this Date is as follows :—

Item. Particulars. Received by Myself. Received by my Wife. Received by my Children under Fifteen.
1 Salary, wages, or other personal earnings .. £ £ £
2 Profits from business (shop, farm, &c.) ..
3 Allowances from relatives or others ..
4 Money derived from rent of property ..
5 Money derived from sale of gold or gum ..
6 Money received as compensation for injury ..
7 Military, civil, superannuation, or other pension ..
8 Annuity from life-assurance company or other sources
9 Dividends from shares or debentures ..
10 Interest on money lent, in bank, or elsewhere ..
11 Income from any other source (such as legacy, life insurance, &c.)

Names and addresses of employer or other persons from whom income received :—

Item :
Item :
Item :
Item :
Item :
Item :

Property owned in New Zealand or Elsewhere by Myself, Wife, and Children under Fifteen Years of Age :—

Item. Particulars. Owned by Myself. (Value.) Owned by Wife. (Value.) Owned by Children under Fifteen. (Value.)
1 Land and house property used as a home (description): £ £ £
2 Land and house property not used as a home (description) :
3 Cash in hand or in any bank (produce bank-book) ..
4 Money lent to, or in hands of, any person (give name and address) :
5 Live-stock (sheep, cattle, horses, poultry, bees, &c.) :
6 Shares, debentures, or bonds in any company or society (particulars) :
7 Interest in business, stock in trade, or venture of any kind (particulars) :
8 Any other property not specified above (particulars) :
Totals .. .. .. £

Property as above (Item ) is mortgaged to (full name and address).

Amount owing on mortgage at present time : £ . Yearly rate of interest : £ .

In support of my application I do solemnly and sincerely declare as follows :—
(1.) That the contents of this my application are correct in every detail.
(2.) That I have not transferred any property or income in order to qualify for an allowance.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1908.

Declared at , this day of , 192 , before me—

{ Justice of the Peace.
Solicitor.
Clerk of Court.
Postmaster.
Constable.
Registrar of Pensions.
Commissioner of Pensions.
}

Post-office at which payment desired if allowance granted :

I, being the mother guardian of the children mentioned in the application herein, do solemnly and sincerely declare as follows :—
(1.) That the said children are under my care and control.
(2.) That the said children have been resident in New Zealand for the twelve months preceding this date.



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✨ LLM interpretation of page content

🏥 Regulations under the Family Allowances Act, 1926 (continued from previous page)

🏥 Health & Social Welfare
Family Allowances, Regulations, Application Procedures, Identity Certificates, Commissioner Powers