1978
THE NEW ZEALAND GAZETTE.
[No. 39

Form No. 14.

Under the Pensions Act, 1926.

AGENT’S WARRANT.

(To be surrendered on payment of the last instalment on attached certificate.)

District :

Pension No.

I HEREBY direct that the instalments of pension payable pursuant to the attached pension-certificate shall be payable for the benefit of the pensioner to [Full name, occupation, and address].

Commissioner of Pensions.

Countersigned :

Date :

CAUTION.—An agent appointed under this warrant is not authorized to collect an instalment after the death of the pensioner, or while the pensioner is in prison, or an inmate of a mental hospital or charitable institution, or not residing in New Zealand.

Form No. 15.

Under the Pensions Act, 1926.

INCOME AND PROPERTY STATEMENT (OLD AGE).

For the Income-year ended 1st , 19

Claim No. Previous pension, £

Pension-certificate No.

To the Registrar of Pensions at

I, THE undersigned, make claim for a renewal of my old-age pension as above.

My full name is

My full address is

The full name and address and amount of pension of my husband [wife] are—

Name :

Address :

Amount of husband’s [wife’s] pension : £

I desire instalments paid at the Post-office.

It is my wish that my pension shall continue to be drawn by—

Name :

Occupation :

Address :

Income of myself and of my wife [husband] during last twelve months :—

Names and addresses of employer or other persons from whom above income received :—

Item :

Item :

Item :

Item :

Item :

Item :

Are you working now ; if so, for what rate of pay ?

Is your wife [husband] working now ; if so, for what rate of pay ?

State names and addresses of employers in each case :

Actual date of receipt of lump-sum payments above :

Do you anticipate receiving income or property at any time during the next twelve months ?

Supply particulars :

Property owned by me and by my husband [wife] is as follows :—

My property as above is mortgaged to [Give full name, address, and occupation of mortgagee] :

Amount owing by me on mortgage at the present time is—

On home and furniture .. .. .. £

On other property .. .. .. £

The property of my husband [wife] is mortgaged to [Give full name, address, and occupation of mortgagee] :

Amount owing by my husband [wife] on mortgage at the present time is—

On home and furniture .. .. .. £

On other property .. .. .. £

Property sold or transferred by me, or by my husband [wife], during the past year is as follows :—

The money received by me for transfer of above property has been disposed of as follows :

The money received by my husband [wife] for transfer of above property has been disposed of as follows :

In support of my application I solemnly and sincerely declare as follows :—

(1) That the contents of this my application for renewal of pension are correct in every detail

(2) That to the best of my knowledge and belief I have fulfilled all the requirements of and am exempt from all disqualifications 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 Pensioner.]

Declared by the said at , this day of , 19 , before me—

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