JUNE 9.] THE NEW ZEALAND GAZETTE. 1977

Any money received by me from transfer of above property has been disposed of as follows:—
The following questions are asked with the sole object of ascertaining whether assistance can be rendered to you apart from pension:—
Have you had any training of any sort to assist you in earning a living or in occupying your time?
If so, by whom trained?
State class of training received:
Have you any wish to undertake any form of training or employment? If so, state the nature of same:
If not regularly employed, can you do anything—
(a) In the way of work about your home?
(b) In walking about without assistance?
(c) In the way of games?
(d) In any other way?
Have you any ideas as to any direction in which your position might be improved?
Have you had any association with the trustees of the Sir Arthur Pearson Memorial Fund, or of the Jubilee Institute for the Blind, Auckland?

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 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].

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:

Form No. 11.
Under the Pensions Act, 1926.
PENSION ADVICE.

(This instalment is payable only for one calendar month after due date unless specially authorized.)
[Issuing-office Stamp.]

Instalment due on 1st
Pension-certificate No.

Pension district:
To the Postmaster of
Pay the sum of pounds shillings and pence, on production of the pensioner’s certificate.

£ s. d.
Initials. | Paying-office Stamp.

Commissioner of Pensions.

I HEREBY acknowledge the receipt of the above-named sum.

[Signature of pensioner or agent.]
[Signature of witness to mark (if payee unable to write) or to signature of Maori]:

• Warrant produced under section , dated
• Pensioner actually residing at .

IMPORTANT.—When the instalment is remitted direct to the pensioner (or agent) by registered letter, the paying officer will note hereunder:—
Registered-letter number:
Office of delivery: [Initials of paying officer.]

• To be used only when paid to an Agent. Insert section 66 or 67 as required, date, and nearest post-office.

Form No. 12.
Under the Pensions Act, 1926.
APPLICATION FOR WARRANT UNDER SECTION 66, AND FORM OF WARRANT.

NOTES.—No payment will be made under this warrant in respect of a deceased pensioner unless the special authority of the Commissioner has first been obtained. A separate warrant is required for each institution controlled by any governing body.)

On behalf of [Name of the Charitable Aid or Hospital Board, or other charitable society] I, , Secretary [or Treasurer] of the said body, hereby make application for a warrant authorizing the payment to it of the instalments of pension as specified in the following schedule, the pensioner in each case having been maintained in the [Name of institution]. And in support of this application I hereby solemnly and sincerely declare that the said governing body has, in the case of each pensioner, maintained or given relief to him for the period set forth opposite his name in the schedule hereunder, and the reasonable cost thereof is as therein mentioned [or, as the case may be, has defrayed the cost of burial].

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—

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

Warrant is hereby granted for the total sum of £ , on the condition that any surplus of pension after defraying cost of maintenance is handed to the pensioner.

Registrar of the Pension District.

Date:

SCHEDULE.

(To be retained by the Postmaster, and forwarded with his accounts.)

Form No. 13.
Under the Pensions Act, 1926.
APPLICATION FOR AGENT’S WARRANT UNDER SECTION 67.

District:
War [Old-age, Widows’, Military, Miners’, Epidemic, Blind]
Pension No.:

NOTES FOR REGISTRARS.

Pensioners may, by making application on Form or , arrange to draw their instalments in person temporarily at any post-office in the Dominion. This does away with the necessity for the issue of a warrant.

No warrant will be issued on behalf of an old-age or military pensioner who is being maintained in or receiving relief from a hospital or charitable institution, unless the application is accompanied by a certificate from the authorities of the institution that they have no claim against the pensioner for maintenance or relief.

Name of pensioner:

I HEREBY apply for a warrant directing that until same is cancelled or expires all instalments of the pension payable pursuant to Pension-certificate No. shall be paid to [Full name of agent, over the age of twenty-one], [Occupation], [Address], on the grounds that [Briefly state grounds].

PLEASE receive pension-certificate herewith.

Witness: [Signature.]
Occupation: Date:
Address:

I CONSENT hereto.

, Proposed payee.

The Commissioner, Wellington

I RECOMMEND issue of warrant in this case. The pension-certificate is attached.

Registrar [or Postmaster].

Date:

HEAD OFFICE NOTINGS.

Warrant and pension-certificate issued to agent, , 19
Examined and despatched: File: