JUNE 9.] THE NEW ZEALAND GAZETTE. 1973

Money owned by me or my children under fifteen years of age
is as follows :-

Other property owned by me or my children under fifteen
years of age is as follows :-

Cash in hand.. .. .. .. .. £
Money lent to, or in hands of [Give name and address]
Live-stock (sheep, cattle, horses, &c.) .. ..
Value of shares, debentures, or bonds in any company, institution, building or other society (particulars)
Value of interest in business, stock-in-trade, or venture of any kind (particulars) .. ..
Any other property not already specified (particulars) .. .. .. .. ..
Total .. .. £

Particulars of bill of sale or mortgage on any of this property are as follows :
If any of this property is insured, state which, and give amount of insurance :
The following property, owned by me or my children, has been transferred or sold during the past twelve months :-

The money received by me for transfer of above property has been disposed of as follows :
In addition to property now owned, or transferred as shown in the foregoing statement, money or other valuable consideration received by me, or by my children under fifteen years of age, during the past twelve months has been disposed of as follows :
In the event of a pension being granted to me, I desire—

1. That instalments be made payable at the post-office at
   [NOTE : Payment can be arranged at any post-office which is not a money-order office, by registered letter.]
2. That, on account of my physical inability to attend at a post-office, instalments be made payable for the benefit of myself and children to—.
   Full name :
   Occupation and address :
   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 the 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, 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.
   ................................
   Postmaster, Clerk of Court, Constable, or Registrar of Pensions.
   Date :

MAGISTRATE’S NOTES.
I HAVE investigated the application herein, and find the following facts proved :-

1. Applicant is a widow.
2. Applicant is a British subject.
3. Applicant has children who are under fifteen years of age.
4. Applicant has been resident in New Zealand for
5. Applicant has not transferred property to qualify for the pension.
6. Applicant is of sober habits and of good moral character.
7. The income of applicant and such of her children as are under fifteen years of age is as follows :-

Notes :
Decision :
Date : Stipendiary Magistrate.

Form No. 3.
Under the Pensions Act, 1926.
STATEMENT IN REGARD TO NATIVE LAND.
Claim No. District :
Full name of applicant :
Other names known by :
Address :
Name of tribe or hapu :

PARTICULARS of all land in respect of which I claim or possess any customary rights or any interest are as follows :-

Particulars of Land disposed of during Last Year.

Full name of husband [wife] :
Other names known by :
Address :
Name of tribe or hapu :

PARTICULARS of all land in respect of which my husband [wife] claims or possesses any customary rights or any interest are as follows :-