1976
THE NEW ZEALAND GAZETTE.
[No. 39

My full name is
Address :
Present occupation :
Occupation before loss of sight :
If pension granted, payment is desired at post-office at
Full name, occupation, and address of person (if any)
desired to collect pension on my behalf :
Date of birth :
Place of birth :
If naturalized, give date and place of naturalization in New
Zealand, and produce naturalization papers :—
Date of naturalization : Place of naturalization :
State if single, widowed, or married :
If married, full name of husband [wife] :
Date of arrival in New Zealand :
Port of arrival : Name of ship :
If absent from New Zealand since arrival, state period :
State reason for absence :

During the last ten years I have resided in the following towns
or districts in New Zealand :—

Date of loss of vision : Place of loss of vision :
Cause of loss of vision :
Condition of right eye : Condition of left eye :
Name and address of eye-specialist whom you have consulted :
What is last advice you received from specialist ?
[NOTE.—Submit any medical evidence you have in regard to
your loss of sight.]

Name and address of well-known person (not a relative) who
knows my circumstances :

The income of myself and my husband (wife) during the past
twelve months was as follows :—

1. Salary, wages, or other earnings (present weekly rate, £ )
2. Profits from business of [State class of business]
3. Superannuation or other class of pension (annual amount)
4. Annuity from life-insurance company or other source (annual amount)
5. Allowance from relatives, Hospital Board, or other society or person
6. Estimated value of free board and lodging provided
7. Money derived from rent of property
8. Money derived from sale of milk, eggs, honey, grain, or other produce
9. Interest from money lent or on mortgage, in bank, or other institution
10. Dividends from shares, debentures, war loans, or other investment
11. Money left by will or from deceased estate
12. Money from life-insurance company (loan or surrender value, bonus, or sum assured)
13. Money received as compensation for accident or other cause
14. Money obtained from fire insurance or by mortgage on property

Names and addresses of persons from whom the above amounts were received [If amounts under 11, 12, 13, and 14, give date received] :
Item :
Item :
Item :
Item :

Do you anticipate receiving any money during the next twelve months ? (Give particulars)
Number of children of applicant under fourteen, ; between fourteen and twenty-one, ; over twenty-one,

Particulars relating to relatives of applicant still alive over the age of twenty-one years—namely, father, mother, grandparents, brothers, sisters, sons, and daughters :—

Interests in land and house property owned in New Zealand or elsewhere by me and by my husband [wife] :—

Freehold, leasehold, life, or other interest

(Particulars of Native land to be filled in on Form 3.)
The above property is mortgaged for £ to [Give full name, address, and occupation of mortgagee] :

Money owned in New Zealand or elsewhere by me and by my husband [wife] :—

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

Value of other property owned in New Zealand or elsewhere by me and by my husband [wife] :—

Cash in hand .. .. .. ..
Money lent to, or in hands of [Give name and address] :
Live-stock (sheep, cattle, horses, poultry, bees, &c.) [State number] :
Shares, debentures, war bonds, or bonds in any company or society (particulars) :
Interest in business, stock-in-trade, or venture of any kind (particulars) :
Any other property not already specified above (particulars) :

State the rate of interest received from any money invested : per cent.
Particulars of bill of sale or mortgage on any of this property are as follows :

The following property, owned by me or by my husband [wife] has been transferred or sold during the past twelve months :—