JUNE 9.] THE NEW ZEALAND GAZETTE. 1979

Form No. 16.

Under the Pensions Act, 1926.

INCOME AND PROPERTY STATEMENT (WIDOW).

For the Income-year ended 1st , 19 .

Claim No. Previous pension : £

Pension-certificate No.

To the Registrar of Pensions at

I, THE undersigned, being still a widow, make claim for a renewal of my widow’s pension.

My full name is

My full address is

I desire instalments paid at the Post-office.

It is my wish that my pension shall continue to be drawn by [to be filled in only if agent required]—

Name :

Occupation :

Address :

The following particulars relate to my children under fifteen years of age who are being maintained by me and in respect of whom I am drawing pension :—

Full Name of Child.	State with whom residing.	If at School, give Name of School.	If employed, state where.	If not at School, and not employed, give Reason.

Income of myself and of my children under fifteen during last twelve months :—

Item.	Particulars.	Received by Myself during Year.	Received by my Children during Year.
1	Salary, wages, or other personal earnings (weekly rate £ )	£	£
2	Profits from business (weekly rate £ )
3	Allowances or other consideration from relatives or others (weekly rate £ )
4	Estimated value of free board and lodging (weekly rate £ )
5	Money derived from rent of property (weekly rate £ )
6	Money derived from sale of milk, grain, or produce of any kind (annual)
7	Money derived from sale of gold, gum, or other natural product (annual)
8	Military, civil, superannuation, or other pension (annual)
9	Annuity from life-assurance company or other source (annual)
10	Dividends from shares or debentures (annual)
11	Interest on money lent on mortgage, in bank, or other institution (annual)

LUMP-SUM PAYMENTS.

| 12 | Money left by will or legacy .. .. | | |
| 13 | Money from life-assurance company (such as loan, surrender value, or sum assured) | | |
| 14 | Money received as compensation for accident, death, loss of office, or other cause | | |
| 15 | Money withdrawn from bank or obtained by mortgage on property | | |

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

Item :

Item :

Item :

Item :

Item :

Item :

Actual dates of receipt of lump-sum payments above :

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

State names and address of employer in each case :

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

Supply particulars :

Property owned by me and by my children under fifteen years of age is as follows :—

	Owned by Me.	Owned by my Children.
Land and house property (used as a home) ..	£	£
Land and house property (not used as a home)
Money in hand, in bank, invested, or held on our account
Money lent on mortgage or otherwise ..
Live-stock, shares, or other property (give particulars) :—
Totals, £

The above property is mortgaged to [Give full name and address of mortgagee or his agents] :

Amount owing on this mortgage at the present time is—

On home .. .. .. £

On other property .. .. .. £

Has any money been raised by way of mortgage during the past year ?

If so, to what use was amount put ?

Property sold or transferred by me during the past year is as follows :—

Description.	Name and Address of Person to whom sold or transferred.	Date of Transfer.	Amount received for Transfer.
Land and house property ..
Cash or money on mortgage ..
Live-stock, shares, &c. ..
Interest in business ..
Any other property (particulars) :—

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

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

(1) That I am still a widow, and maintaining my children under fifteen.

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

(3) 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].

Form No. 17.

Under the Pensions Act, 1926.

INCOME AND PROPERTY STATEMENT (MENTAL PATIENT).

For the Income-year ended 1st 19

Claim No. Previous pension : £ Pension No.

District :

I, THE undersigned, hereby make claim for a renewal of the old-age pension granted to , who is at the present time an inmate of the Mental Hospital.

Payment of the pension is desired at the Post-office.

Medical Superintendent.

Date :

In the matter of the above application, I hereby certify that the property owned by the above-named inmate of the Mental Hospital, who, I understand, is still alive, is as follows :—

	Value.
Land and houses (freehold, leasehold, or other tenure) [Quote block and section numbers] ..	£
Money in hand, in bank, or lent out on mortgage
Stock, furniture, shares, or other property [Give description] .. .. .. ..
Total .. .. .. ..	£

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