✨ Pension Application Form
June 9.] THE NEW ZEALAND GAZETTE. 1971
I first arrived in New Zealand on the day of , 18 , at the port of in the ship , which sailed from . The captain’s name was .
Since I first arrived in New Zealand I have been absent from New Zealand on the following occasions:—
| Date of Departure. | Port of Departure. | Name of Ship. | Date of Return. | Port returned to. | Name of Ship. | Period absent. |
|---|---|---|---|---|---|---|
| Years. mos. |
I have lived in the following towns or districts in New Zealand, and the persons named against each place can verify my residence there:—
| Town or District. | Actual Years of Residence. | Name and Address of Person who can verify my Residence there. |
|---|---|---|
| 18 to 18 to to |
Have you made previous application for a pension? If so, where?
Have you ever married? If so, give place and date: If married, give full name of husband [or wife—to include maiden name] even if dead:
Is your husband [wife] an old-age pensioner? If so, in what district?
Why is your husband [wife] not an old-age pensioner?
Are you living together? If not, are you living apart pursuant to decree, order, deed of separation, or mutual consent?
The income of myself and of my husband [wife] during the twelve months preceding this date is as follows:—
| Item. | Particulars. | Received by Myself during Year. £ | Received by my Wife [Husband] during year. £ |
|---|---|---|---|
| 1 | Salary, wages, or other personal earnings (weekly rate £ ) | ||
| 2 | Profits from business (weekly rate £ ) | ||
| 3 | Allowances or other consideration from relatives or others (weekly rate £ ) | ||
| 4 | Estimated value of free board and lodging (weekly rate £ ) | ||
| 5 | Money derived from rent of property (weekly rate £ ) | ||
| 6 | Money derived from sale of stock, milk, grain, fruit, honey, or produce of any kind (annual) | ||
| 7 | Money derived from sale of gold, gum, or other natural product (annual) | ||
| 8 | Military, civil, superannuation, or other pension (annual) | ||
| 9 | Annuity from life-assurance company, deceased estate, or other source (annual) | ||
| 10 | Dividends from shares or debentures (annual) | ||
| 11 | Interest on money lent on mortgage, in bank, or other institution (annual) | ||
| 12 | Income from any other source not shown above (annual) |
LUMP-SUM PAYMENTS.
| 13 | Money left by will or legacy .. | |
| 14 | Money from life-assurance company (such as loan, surrender value, or sum assured) | |
| 15 | Money received as compensation for accident, death, loss of office, or other cause | |
| 16 | Money withdrawn from bank, obtained by mortgage on property, or in any other way | |
Names and addresses of employer or other persons from whom above income received:—
Item :
Item :
Item :
Item :
Item :
Item :
Are you working now; if so, for what rate of pay?
Is your husband [wife] working now; if so, for what rate of pay?
State names and addresses of employers in each case:
Actual date of receipt of lump-sum payments above:
Do you anticipate receiving income or property at any time during the next twelve months?
Supply particulars:
The following interests in land and houses in New Zealand or elsewhere are owned by me and my husband [wife]:
| Description. | Section and Block Nos. | Locality. | Area. | Government Valuation. £ |
|---|---|---|---|---|
| In my name— | A. R. P. | |||
| Freehold .. .. | ||||
| Leasehold .. .. | ||||
| Life or other interest .. | ||||
| In name of husband [wife]— | ||||
| Freehold .. .. | ||||
| Leasehold .. .. | ||||
| Life or other interest .. |
NOTE.—Particulars of Native land to be supplied on separate form No. 3.
State what part of property above mentioned is used as a home:
My property as above is mortgaged to [Give full name, address, and occupation of mortgagee]:
The amount owing on this mortgage at the present time is £
The property of my husband [wife] is mortgaged to [Give full name, address, and occupation of mortgagee]:
The amount owing on this mortgage at the present time is £
To what use was money raised on mortgage put?
The value of my furniture and personal effects is [If insured, give insured value] £
The value of my husband’s [wife’s] furniture and personal effects is [If insured, give insured value] £
Money owned by me and by my husband [wife] in New Zealand or elsewhere is as follows:—
| In my Name. | In Name of my Husband [Wife]. | |
|---|---|---|
| Amount. | If Account closed, give Date. | |
| In Post-office Savings-bank .. | ||
| Bank of New Zealand .. | ||
| Bank of New South Wales .. | ||
| Bank of Australasia .. | ||
| Union Bank of Australia .. | ||
| National Bank of N.Z. .. | ||
| Commercial Bank .. | ||
| Any other institution .. | ||
| Any building society .. | ||
| Totals .. ..£ |
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VUW Te Waharoa —
NZ Gazette 1927, No 39
NZLII —
NZ Gazette 1927, No 39
✨ LLM interpretation of page content
🏥
Regulations under the Pensions Act, 1926
(continued from previous page)
🏥 Health & Social Welfare6 June 1927
Pensions Act, Regulations, Old-age pensions, Widows' pensions, Military pensions, Miners' pensions, Blind pensions