1980
THE NEW ZEALAND GAZETTE.
[No. 39

The property is mortgaged to—
Name :
Address :
The amount of mortgage owing at the present time is £
I hereby further certify that for the year ended as above
the total income of the pensioner was as follows :—
£ s. d.
Money derived from property owned .. ..
Wages or other personal earnings .. ..
Money left by will or legacy .. ..
Insurance-money received .. ..
Money received from relatives or any other source
Total .. .. .. £
……………
Public Trustee.

Date :
——

[To be filled in if the Pensioner is married.]
In the matter of the application herein for a renewal of
the pension granted to , who is at present an inmate
of the Mental Hospital, I, wife [husband]
of the said do hereby solemnly and sincerely declare
as follows :—
(1) That for the year ended as stated herein my total
income was—
£ s. d.
Money derived from property owned by me
Money withdrawn from bank or other
institution .. .. ..
Wages or other personal earnings ..
Money left by will or legacy .. ..
Insurance-money received .. ..
Money received from relatives or any other
source .. .. ..
Estimated cost of free board and lodging :..
Total .. .. £

The names and addresses of the persons from whom I
earned or received money are :
——

(2) That the property owned by me is as follows :—
Value.
£
Land and house property (used as a home) ..
Furniture and personal effects [If insured,
give insured value] .. .. ..
Land and house property (not used as a home)
Money in hand, in bank, or lent out ..
Live-stock, shares, or other property [Give
particulars] .. .. ..
My property is mortgaged to—
Name :
Address :
The amount of mortgage owing at the present is—
On home and furniture : £
On other property : £
(3) That I have not lent or disposed of any money, or sold
or transferred any property, during the past year.
(4) That I have not been left any money or property of
any kind during the past year.
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.]

Declared by the said at , this day
of 19 , before me—
……………
Justice of the Peace [Solicitor,
Clerk of Court, Registrar of
Pensions, Postmaster, or
Constable].

To the Registrar for the Pension District.

[Not to be filled in by the Applicant.]
To , Esq., Stipendiary Magistrate.
I HEREBY certify that, as far as I have been able, I have
verified the statements herein, and, having ascertained that
the requirements of section 8 of the Act have [not] been
complied with, I recommend—
(1) That a pension be granted for the sum of £ ,
being the full amount of pension reduced by
£ for property and £ for income.
*(2) That no pension be granted on account of
……………
Registrar at
Date :

• Delete as required.

MAGISTRATE’S NOTES.
I HAVE investigated the application herein, and find the
following points proved :—
——
Pen-
sioner.
Hus-
band
[Wife].
(1) Actual income .. .. ..
Less exemptions .. .. ..
Total net incomes .. ..
(2) Home, £ ; furniture, &c., £ .. ..
Less mortgage .. .. ..
Net .. .. ..
(3) Property (other than home and furniture)
Less (1) mortgage, £ ; (2) allowance, £50
Net .. .. ..
Total net properties .. ..

Notes :
Decision :
……………
Stipendiary Magistrate.

Date :
——

Form No. 18.
Under the Pensions Act, 1926.
CERTIFICATE AS TO RENEWAL OF OLD-AGE PENSION.
For the Income-year ended 1st , 19
District : Pension No.
Name :
Address :
(1) Income (including £ free board Applicant. Husband
and lodging) .. ..£ £ [Wife].
Total income of husband and
wife .. .. .. ===== Half = £=====
Exemption in terms of section……… £……
Deduction on account of income in
excess of £52 .. .. .. £……
Deduction in terms of section 13 (1) (b) £……
(NOTE.—Please indicate if pensioner is single, widowed, or
married.)

(2) Property (other than home)* Applicant. Husband
.. £ £ [Wife].
Deduct allowance.. .. £ 50 £ 50
Net property .. £ £
Total net property of husband
and wife .. .. £ Half = £
Deduction on account of property (£1
every £10) .. .. .. £……
Deduction on account of age .. £……

RECOMMENDATION.
……………
Registrar of Pensions.

Date :

DECISION.
For the year commencing on the 1st day of , 19
a pension of £ is hereby granted [or a pension is
refused on account of ].
……………
Commissioner of Pensions.

Date :

*Particulars of other property :—
£
Less mortgage .. ..
£
Home .. .. .. ..
Furniture and effects .. .. ..
Less mortgage .. .. .. £
——

PAYING OFFICE.
Renewal of warrant under section 67 required in favour
of :
P.C. and warrant and advice issued to P.M. , 19
Charge : District card : Advice :
P.C. : Property return : File :