1972
THE NEW ZEALAND GAZETTE.
[No. 39

Other property owned by me and by my husband [wife] in New Zealand or elsewhere is as follows :—

Give particulars of bill of sale or mortgage on any of this property :

If any property mentioned in this claim is insured, state which, and give amount of insurance and name of company :

The following property has been transferred or sold by me, or by my husband [wife] since 1st November, 1898 :—

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

The money received by my husband [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 statements, money or other valuable consideration has been received and disposed of since the 1st November, 1898, as follows :—

By myself (particulars) :

By my husband [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 of and am exempt from all disqualifications under the Pensions Act, 1926, 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 Justices of the Peace Act, 1908.

[Signature of Applicant.]

Declared by the said
at
this
day
of
, 19
, before me—

Justice of the Peace [Solicitor, Registrar of Pensions, Clerk of Court, Postmaster, Constable, or Commissioner of Pensions].

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.

Clerk of Court, Constable, Postmaster, or Registrar of Pensions.

Date :

TO BE DELIVERED TO THE NEAREST REGISTRAR OF PENSIONS.

Form No. 2.
Under the Pensions Act, 1926.
(This form is to be issued only to or on behalf of a bona fide applicant for pension.)
WIDOW’S PENSION CLAIM.

To the Registrar of Pensions at
I, THE undersigned, being a widow, hereby apply for a pension under the aforesaid Act. I have made previous application for the pension under name of
at
My present full name is
My former full name [or names] was [were]
My full address is
My occupation is [or was]
I have lived previously in New Zealand at [Give years of residence in each place]
I was born at
, in the country of
, on the
day of
, 18
I am a British subject [State if by birth or naturalization] : If naturalized, give date and place of naturalization, and produce naturalization papers of self or late husband :
I arrived in New Zealand on the
day of
,
1
, at the port of
, in the ship
If absent from New Zealand, state when :
I was married at
, on the
day of
, 1
My late husband’s full name was
He died at
, on the
day of
, 1
His death was registered at
The total number of children born to me is [Quote number only]

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

The name and address of a person [who must be well known and not a relative] who knows my circumstances are as follows :

The income of myself, and of such of my children as are under the age of fifteen years, during the past twelve months has been as follows :—
£

1. Salary, wages, or other personal earnings (present weekly rate £
   )
   ..
   ..
   ..
2. Profits from business
   ..
   ..
   ..
3. Superannuation or other pension [Quote annual amount payable]
   ..
   ..
   ..
4. Annuity from life-assurance company or other source [Quote annual amount payable]
   ..
5. Money left by will or legacy
   ..
   ..
6. Dividends from shares, debentures, or investments 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 produce 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
..
..
£

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

The following interests in land and house property are owned by me or my children under fifteen years of age :—

NOTE.—Particulars of Native land to be supplied on separate form.

What part of above property is used as a home ?

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

The amount owing on this mortgage at the present time is £