1974
THE NEW ZEALAND GAZETTE.
No. 39

Particulars of Land disposed of Last Year by my Husband [Wife].

This statement relates to my application for pension bearing this day’s date.

[Signature of Applicant.]

Date :

THIS is to certify that the contents of this statement were fully explained to and appeared to be fully understood by the applicant.

[Signature.]
[Official designation.]

Date :

Form No. 4.
Under the Pensions Act, 1926.
MEMORANDUM OF REJECTION.

To the Registrar, District.

Old-age [Widow’s] Pension Claim No. , made by
I HEREBY certify that the above-numbered claim has this day been investigated by me, and my decision is that it is rejected on the following grounds [If on account of income or property, please supply details] :

The following material points have been proved :
Dated at , this day of , 19
Stipendiary Magistrate.

Noted in Pension-claim Register, and applicant notified on Form .

[Initials of Registrar.]

HEAD OFFICE NOTINGS.

Claim Reg. : Claim-card : File :

Form No. 5.
Under the Pensions Act, 1926.
MAGISTRATE’S CERTIFICATE OF ESTABLISHMENT OF OLD-AGE PENSION CLAIM.

Pension-claim No. District : Pension-certificate No.

I HEREBY certify that the above-numbered pension-claim made by , [Occupation; if no present occupation, state former occupation], [Address], has this day been investigated by me, and the following facts have been proved before me :—

1. Age by [State briefly the nature of the proof].
2. The applicant has fulfilled the conditions set out in the Pensions Act, 1926, section 8, paragraphs (a), (b), (c), (d), (e), (f), and (g).

Applicant. Husband [Wife].

3. Income (including £ free board and lodging) .. .. £ .. £

Total income of husband and wife .. £ Half = £

Exemption in terms of section 2 (paragraph ) .. .. .. £......
Exemption in terms of section 12 .. £......
Deduction on account of income in excess of £52 .. .. .. .. £......
Deduction in terms of section 13 (1) (b) .. £......

Applicant. Husband [Wife].

(4) Property (other than home)* .. £ .. £

Deduct allowance .. £ 50 £ 50

Net property .. £ .. £

Total net property of husband and wife.. £ Half = £

*Particulars of other property :—

£
Less mortgage .. .. ..
£
Home .. .. .. £
Furniture and effects .. .. ..
Less mortgage .. .. ..
£

Deduction on account of property (£1 for every £10) .. .. .. £......
(Note : If applicant is married, see section 13.)
Deduction on account of age .. £......

DECISION.

Applicant is granted a pension of pounds (£ ).*
Dated at , this day of , 19
Stipendiary Magistrate.

Noted in Claim Register and Pension Register.
[Initials of Registrar.]

• Including pension under section 9 (3) of Here state period of absence from New Zealand : £

PARTICULARS TO BE SUPPLIED BY REGISTRAR.

Date of birth : Paying-office :
Nationality (term “ British ” is insufficient) :
Date of naturalization :
Name of husband [wife] :
Pension No. [husband or wife] :
[If not married, state conjugal condition and sex.]

Pension-certificate issued to pensioner , 19
Index-card : District card : Advice : P.C. :
Charge : Sdy. returns : Property return : File :

Form No. 6.
Under the Pensions Act, 1926.
MAGISTRATE’S CERTIFICATE OF ESTABLISHMENT OF WIDOW’S PENSION CLAIM.

Claim No. : District : Pension No.

I HEREBY certify that the above-numbered claim, made by , [Occupation], [Address], has this day been investigated by me, and it has been proved to my satisfaction,—

1. That the applicant fulfils the conditions of the Pensions Act, 1926.
2. That the applicant is the mother of children under the age of fifteen years, and is entitled to a maximum pension of £ , subject to the deduction shown hereunder.
3. That the income of applicant and her children under fifteen years from all sources is as follows :—

£
Income from personal earnings .. ..
Actual net income from property* ..
Actual income from other sources [State nature]† .. .. ..
Constructive income (in terms of section 23)‡
On account of cash .. .. £
On account of other property§ £
Less mortgage .. £

Total net property .. £

5 per cent. of net property* ..
Total income .. .. ..
Income exempted .. .. .. 78

Deduction on account of income in excess .. .. ..
£

4. Value of home, £ ; mortgaged for £

DECISION.

The applicant is granted a pension of £

Date : Stipendiary Magistrate.

• To be included only when amount is more than 5 per cent. of value of property. (See ‡ below.)
  † To include all allowances and any other class of pension.
  ‡ To be included only when amount is more than actual income from property. (See * above.)
  § Particulars of other property.

PAYMENT is desired at the Post-office.
Warrant under section 67 is required on account of in favour of [Full name, occupation, and address]
Noted in Claim Register and in Pension Register.
[Initials of Registrar.]

Pension-certificate issued to pensioner , 19
Index-card : District card : Advice : P.C. :
Charge : Sdy. returns : Property return : File :