JUNE 9.] THE NEW ZEALAND GAZETTE. 1975

Form No. 7.
Under the Pensions Act, 1926.

(The pension payable in terms of this certificate is absolutely inalienable, whether by way of assignment, charge, execution, bankruptcy, or otherwise howsoever.)

Certificate No.

DOMINION OF NEW ZEALAND.

PENSION-CERTIFICATE.

(Not Transferable.)

THIS is to certify that __ (whose signature appears on the back hereof) has been granted an __ [old-age, widow’s, military, or as the case may be] pension of an annual value of £ __, payable by equal monthly instalments of £ __ : __, of which the first instalment is due on the 1st day of __, 19 __,* and each subsequent instalment on the 1st day of each calendar month thereafter, at the post-office at __.

Countersigned: __
Date: __
Commissioner of Pensions.

Specimen signature of pensioner: __

• CAUTION.—Instalments of pensions are payable from the 23rd of the month preceding due date until the 1st day of following month, and should be collected during that period.

Form No. 8.
Under the Pensions Act, 1926.

MILITARY PENSION CLAIM.

To the Commissioner of Pensions, Wellington.

I, THE undersigned, hereby make claim for a military pension under the Pensions Act, 1926.

My full name is __
My full address is __
My wife’s full name is __
My present age is __
If pension granted, I desire payment made at the post-office at __

I have served under the Crown in the Maori Wars as follows:—
Corps in which served: __
Rank: __ Regimental No. (if any): __
Period of service (state actual years): __
Name or locality of any action at which under fire: __
I was awarded the New Zealand War Medal in the year __
[Produce New Zealand War Medal; and if not in possession of same, state why.]

Give name and address of person of repute (for preference a comrade in arms or other veteran) who is able to identify you as the person to whom a New Zealand War Medal was awarded: __

During the past ten years I have lived in the following towns or districts in New Zealand, and the person named against each place can verify my residence there:—

During the past ten years I have been absent from New Zealand on the following occasions:—

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, Postmaster, Constable, or Examining Officer].

THIS is to certify that the applicant has produced his New Zealand War Medal.

A Commissioned Officer of the New Zealand Defence Forces, or Registrar of Pensions.

Date: __
C

Form No. 9.
Under the Pensions Act, 1926.

MINER’S PENSION CLAIM.

Head Office No.: __

I, THE undersigned, being totally incapacitated for work on account of miner’s phthisis, do hereby apply for a pension under the above Act. [Produce medical certificate.]

My full name is __
My full address is __
If pension granted, I desire payment made at the post-office at __
I was born in [country only] __ Present age: __
I am a British subject [State if by birth or naturalization]: __
If naturalized, give date and place of naturalization, and produce naturalization papers: __
I came to New Zealand from __, in the year __
If absent from New Zealand since first arriving, state when: __
Give reason for absence: __

During the last five years I have lived in the following towns or districts in New Zealand, and the person named against each place can verify my residence there:—

The following particulars relate to my mining service in New Zealand:—

When did you first contract miner’s phthisis? __
Supply names and addresses of medical men who have treated you for the complaint: __
Have you followed any other employment since you gave up mining (supply particulars)? __
Are you able to do any work at all? __
On what date did you finally give up work? __
I was married at __, on the __ day of __, 19 __ [Produce marriage certificate if wife still alive.]
Full maiden name of wife: __
Are you living together? __ If not, state why: __

The following particulars relate to such of my children as are under fourteen years of age and are dependent on me for their support. [Produce certificates if you have them.]

Name and address of agent to whom instalments of pension to be paid if applicant unable through physical incapacity to collect in person:—

Name (over twenty-one years of age): __
Address: __

I 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 am entitled to a miner’s pension under the Pensions Act, 1926. 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].

Form No. 10.
Under the Pensions Act, 1926.

PENSION CLAIM IN RESPECT OF BLINDNESS.

Local Claim No. __ H.O. Claim No. __

To the Registrar of Pensions at __

I, THE undersigned, do hereby apply for a pension for total blindness.