Invalid and Old-age Pensions Regulations (Amendment)

STATUTORY RULES

1934. No. 142.

_________

REGULATIONS UNDER THE INVALID AND OLD-AGE PENSIONS ACT 1908-1933.*

I, THE GOVERNOR-GENERAL in and over the Commonwealth of Australia, acting with the advice of the Federal Executive Council, hereby make the following Regulations under the Invalid and Old-age Pensions Act 1908-1933.

Dated this seventh day of November, 1934.

ISAAC A. ISAACS

Governor-General.

By His Excellency’s Command,

R. G. CASEY

for Treasurer,

_________

Amendment of the Invalid and Old-age Pensions Regulations. †

Repeal of Regulations 38, 39 and 40.

1. Regulations 38, 39 and 40 of the Invalid and Old-age Pensions Regulations are repealed.

Forms 2 and 3 repealed and new Forms substituted.

2. Forms 2 and 3 in the Invalid and Old-age Pensions Regulations are repealed and the following Forms inserted in their stead:—

Form 2.

“Commonwealth of Australia.

The Invalid and Old-age Pensions Act 1908-1933.

OLD-AGE PENSION CLAIM.

Attention is directed to section 27 (4.) of the Act, which reads as follows:—

Every claimant shall, by declaration to be indorsed thereon, declare that the contents of his pension claim are true and correct in every particular, and if in the declaration or claim he wilfully makes any statement which is untrue in any particular, he shall be guilty of an offence.

Penalty: One hundred pounds or imprisonment for one year.

* Name of Claimant in full.

† Residence (Postal Address).

‡ Occupation.

I,* .....................................................................

of†.....................................................................

‡......................................................................

hereby claim an Old-age Pension under the Invalid and Old-age Pensions Act 1908-1933.

I affirm that, in respect of an Old-age Pension, I have all the qualifications and requirements, and nave not any of the disqualifications, under the above-mentioned Act.

My place of abode is at. ………………………………………………………………………. where I have resided for a period of …………………………………………………………………… and my place or places of abode during the last twelve months have been ………………………………………………………………………………………………………….

________________________________________________________________________________

* Notified in the Commonwealth Gazette on 15th November, 1934.

† Statutory Rules 1925, No 178; as amended by Statutory Rules 1929, Nos. 9 and 110; 1930, Nos. 4 and 11; 1931, No. 91; 1932, No. 122; 1938, Nos. 4, 41, 53 and 144; and 1934, Nos. 12, 69, and 112.

4874.—Price 8d.

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td colspan="2" style="border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-indent:14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">The information given in answer to the questions hereinafter act out is true and correct.</span></p></td></tr><tr style="height:35.7pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">QUESTIONS.</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">ANSWERS.</span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Where were you born?</span></p><p style="margin-left:18pt; margin-bottom:0pt; text-indent:13.5pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Name the place and country.)</span></p><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.3pt">(If you have documentary proof of age, it should, </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">if practicable, be attached to this page.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">When were you born?</span></p><p style="margin-left:25.05pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Give exact date if possible.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">If you were not horn a British subject are you </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">naturalized? If so, when and where were </span><span style="font-family:'Times New Roman', serif">you naturalized?</span></p><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-10.95pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">(Papers or other evidence must be produced to </span><span style="font-family:'Times New Roman', serif">the Magistrate.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">If you were not born in Australia, when did you </span><span style="font-family:'Times New Roman', serif">first arrive in Australia?</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.3pt">From what port did you sail for Australia? What </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">was the name of the ship and at what port </span><span style="font-family:'Times New Roman', serif">did you land?</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">Were you a passenger or immigrant or member </span><span style="font-family:'Times New Roman', serif">of crew?</span></p><p style="margin-left:25.05pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(State which.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.35pt">Since you first arrived for Australia have you visited </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">New Zealand or any other country?</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">If so, how long altogether were you away from </span><span style="font-family:'Times New Roman', serif">Australia?</span></p><p style="margin-left:25.05pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.35pt">(Give full particulars, including dates of departure </span><span style="font-family:'Times New Roman', serif">from, and return to, Australia.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Are you single, married, a widow a widower or a </span><span style="font-family:'Times New Roman', serif">divorcee?</span></p><p style="margin-left:11.55pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(State which.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">If you are married what is the full name of your </span><span style="font-family:'Times New Roman', serif">husband or wife?</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Where and when were you married?</span></p><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-6.45pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Give exact date if possible.)</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:58.74%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">If you are widow or married woman, what was </span><span style="font-family:'Times New Roman', serif">your maiden name?</span></p></td><td style="width:41.26%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:10.9pt"><td rowspan="2" style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">QUESTIONS.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">ANSWERS.</span></p></td></tr><tr style="height:64.5pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.3pt">(in the case of married persons, information </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">is required concerning both husband and wife</span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning </span><span style="font-family:'Times New Roman', serif">Claimant.</span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.3pt">Information concerning </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Claimant’s Wife or </span><span style="font-family:'Times New Roman', serif">Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">How much per week are you earning now? </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">(If earning, give name and address of employer.)</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">By whom were you employed during the last twelve months?</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">How much did you earn during the last twelve months?</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you receive board or lodging either free or in return for services?</span></p><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-1.95pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">(State which, for how long and from whom </span><span style="font-family:'Times New Roman', serif">received.)</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">How much per week are your relatives (husband, wife, father, mother or children) contributing towards your maintenance?</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you keep a shop or lodging-house or boarding-house, or conduct a business of any kind, or have you an interest in any shop or business?</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">What is the nature of the shop or business, and what were the gross receipts and profit during the last twelve months?</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Has anyone agreed to maintain you wholly or partially or to make any payments to you in consideration of property you have transferred?</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.34%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Are you in receipt of a War Pension or any other allowance from the Repatriation Department or any other pensioner superannuation allowance? (If so</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">, </span><span style="font-family:'Times New Roman', serif">give full particulars.)</span></p></td><td style="width:19.7%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

4874.—8

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td rowspan="2" style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">QUESTIONS.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.15pt">(In the Case of Married Persons, Information </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.1pt">is required Concerning Both Husband and </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Information concerning </span><span style="font-family:'Times New Roman', serif">Claimant.</span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">Claimant’s Wife or </span><span style="font-family:'Times New Roman', serif">Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">What other income have you received during the last twelve months?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">(Reply should include rents, after deduction of repairs &amp;c.,</span><span style="font-family:'Times New Roman', serif; font-style:italic; letter-spacing:-0.2pt"> </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">dividends from banks or </span><span style="font-family:'Times New Roman', serif">companies, interest on bonds or on money lent or on money in banks, </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">income from a deceased estate </span><span style="font-family:'Times New Roman', serif">and any other form of receipts. </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">The nature and amount of the income </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">in each case should be stated.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you at any time applied for an Invalid or Old-age Pension? If so</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">, </span><span style="font-family:'Times New Roman', serif">when and where?</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own or have you an interest in any house or land property?</span></p><p style="margin-left:34.05pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">(Property includes freehold, leasehold and </span><span style="font-family:'Times New Roman', serif">property being purchased by instalments.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">If so, where is it situated? (Give full particulars.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">What is the full capital value?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">(Where a valuation of the property has been </span><span style="font-family:'Times New Roman', serif">made for any local authority, the last </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">notice of assessment or a letter from an official of such local authority, stating </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">the capital value as assessed, must be </span><span style="font-family:'Times New Roman', serif">sent, placed to this page, to the Registrar of Pensions.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">If you own or have an interest in only one house, do you live in it?</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">If you own or have an interest in more than on a house, which of those mentioned above do you live in?</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:62.7%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Is any of your property subject to a mortgage or other encumbrance?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, state clearly which property is encumbered;</span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt"> also the name and address </span><span style="font-family:'Times New Roman', serif">of the person to whom the money is </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">owing and the amount of the debt.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.52%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:11.25pt"><td rowspan="3" style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Q</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">uestions</span><span style="font-family:'Times New Roman', serif">.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:51.35pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.25pt">(In the Case of Married Persons, Information </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.2pt">is Required Concerning both Husband and </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Wife.).</span></p></td></tr><tr style="height:1pt"><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Information concerning </span><span style="font-family:'Times New Roman', serif">Claimant.</span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Claimant’s Wife or </span><span style="font-family:'Times New Roman', serif">Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you a share or interest in any other property?</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">What is the nature and value of each share or interest?</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own any horses, cattle, sheep, or other live stock, or any vehicles, implements, &amp;c.? (Give particulars and value.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any interest in a deceased estate, or under any settlement, deed of gift, or deed or declaration of trust? (Give full particulars.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any money in any bank, savings bank, building society, or other institution, or any money in hand?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">(If so, give details as to amounts, name and </span><span style="font-family:'Times New Roman', serif">address of bank, &amp;c.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Is your life insured?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.35pt">(If so, state name of company, policy number, </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">amount, and age at which amount pay</span><span style="font-family:'Times New Roman', serif">able also state by whom premiums are paid.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own any Government or other bonds or stock or industrial shares, or have you lent money to any person on mortgage or in any other manner?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, give particulars.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any real or personal property not elsewhere disclosed in this statement? (If so, give particulars.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you during the past five years transferred or otherwise disposed of money or other property of any kind?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">(If so, give particulars how disposed of and </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">to whom, and the value received there</span><span style="font-family:'Times New Roman', serif">for.)</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:65.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">At what Post Office do you desire your pension, if granted, to be paid?</span></p></td><td style="width:18.78%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.36%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

Signature of Claimant.........................

Declaration

* Name of Claimant.

† Residence and Occupation.

I,*.....................................................................

of†.....................................................................

.......................................................................

the above-named claimant for an Old-age Pension under the Invalid and Old-age Pensions Act 1908-1933 do hereby declare that the contents of my pension claim on which this declaration is indorsed are true and correct in every particular.

Before me—

‡§..................................

..............................

‡The person on before whom this declaration is made to sign here and add the title by which be takes the declaration, such as “Postmaster,” &c.

§ The declaration may be made before any of the following persons:—A postmaster or postmistress, or person in charge of a post office, a permanent officer of the Postmaster-General’s Department whose duties include the payment of invalid or old-age pensions, a police, stipendiary, or special magistrate of the Commonwealth or of a State, a justice of the peace, a barrister or solicitor, a State school head teacher, an officer of the Department of Trade and Customs, a member of the police force of the Commonwealth or of a State, a legally qualified medical practitioner, a notary public, a commissioner for affidavits, a commissioner for declarations, a registrar under the Invalid and Old-age Pensions Act 1908-1933, a minister of religion, an officer of the Commonwealth Department of the Treasury, a councillor of any municipality or shire, or a member of the Parliament of the Commonwealth or of any State.

______

Form 3.

“Commonwealth of Australia.

The Invalid and Old-age Pensions Act 1908-1933.

INVALID PENSION CLAIM.

Attention is directed to section 27(4.) of the Act, which reads as follows:—

Every claimant shall, by declaration to be indorsed thereon, declare that the contents of his pension claim are true and correct in every particular, and if in the declaration or claim he wilfully makes any statement which is untrue in any particular, he shall be guilty of an offence. Penalty: One hundred pounds or imprisonment for one year.

* Name of Claimant in full.

† Residence (Postal Address).

‡ Occupation.

I,*.....................................................................

Of†....................................................................

‡......................................................................

hereby claim an Invalid Pension under the Invalid and Old-age Pensions Act 1908-1933.

I affirm that, in respect of an Invalid Pension, I have all the qualifications and requirements, and have not any of the disqualifications, under the above-mentioned Act.

My place of abode is at………………………………………………………………………………. where I have resided for a period of…………………………………………………………………… and my place or places of abode during the last twelve months have been …………………………………………………………………………………………………………

The information given in answer to the questions hereinafter set out is true and correct.

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:12.5pt"><td rowspan="3" style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">QUESTIONS.</span></p></td><td colspan="3" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">ANSWERS.</span></p></td></tr><tr style="height:37.55pt"><td colspan="3" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.25pt">(In The Case of Married Persons, Information </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.2pt">is Required Concerning Both Husband And </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Wife.)</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Information concerning Claimant’s Wife or Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">How much per week are you earning now?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">(If earning, give name and address of employer.)</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">By when were you employed during the last twelve months?</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">H</span><span style="font-family:'Times New Roman', serif">ow</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps"> </span><span style="font-family:'Times New Roman', serif">much did you earn during the last twelve months?</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you receive board or lodging either free or in return for services?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">(State which, for how long and from whom </span><span style="font-family:'Times New Roman', serif">received.)</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">How much per week are your relatives (husband, wife, father, mother or children) contributing towards your maintenance?</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you keep a shop or lodging-house or boarding house or conduct a business of any kind, or have you an interest in any shop or business?</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">What is the nature of the shop or business, and what were the gross receipts and profit during the last twelve months?</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Has anyone agreed to maintain you wholly or partially or to make any payments to you in consideration of property you have transferred?</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:54.76%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Are you in receipt of a War Pension or any other allowance from the Repatriation Department or any other pension or superannuation allowance?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, give full particulars.)</span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:8.96%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:27.32%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:11.9pt"><td rowspan="3" style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Q</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">uestions</span><span style="font-family:'Times New Roman', serif">.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:50.7pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.2pt">(In The Case of married Persons, information is Required Concerning Both Husband and </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.3pt">Information concerning </span><span style="font-family:'Times New Roman', serif">Claimant.</span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning Claimant’s Wife or </span><span style="font-family:'Times New Roman', serif">Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">What other income have you received during the last twelve months?</span></p><p style="margin-left:34.05pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">(Reply should include rates, after deduction </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">of repairs, &amp;c., dividends from banks or </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">companies, interest on bonds or </span><span style="font-family:'Times New Roman', serif">money lent or on money in banks, </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">income from a deceased estate, and any, o</span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">ther form of receipts. The nature and a</span><span style="font-family:'Times New Roman', serif">mount of the income in each case should be stated.)</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any claim against any employer, company, or any other person, or body to maintain or compensate you on account of accident or invalid state of health?</span></p><p style="margin-left:25.05pt; margin-bottom:0pt; text-indent:-13.5pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, state full particulars.)</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you ever received compensation on account of accident or ill-health?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, state full particulars.)</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you at any time applied for an Invalid or Old-age Pension? If so</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">, </span><span style="font-family:'Times New Roman', serif">when, and where?</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own or have you an interest in any house or land property?</span></p><p style="margin-left:20.55pt; margin-bottom:0pt; text-indent:-13.5pt; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">(Property includes </span><span style="font-family:'Times New Roman', serif">freehold</span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">, leasehold and </span><span style="font-family:'Times New Roman', serif">property being purchased by instalments.)</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">If so, where is it situated?</span></p><p style="margin-left:34.05pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Give full particulars.)</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">What is the full capital value?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">(Where a valuation of the property has been </span><span style="font-family:'Times New Roman', serif">made for any local authority, the last </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">notice of assessment or a letter from an official of each local authority, stating </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">the capital value as assessed, must, he </span><span style="font-family:'Times New Roman', serif">sent, pinned to this page, to the Registrar of Pensions.)</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:64.38%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">If you own or have an interest in only one house, do you live in it?</span></p></td><td style="width:16.96%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:18.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:12.5pt"><td rowspan="3" style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Questions</span><span style="font-family:'Times New Roman', serif">.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:50.1pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.25pt">(In The Case Of Married Persons, Information </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps; letter-spacing:-0.15pt">Required Concerning Both Husband And </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Information concerning </span><span style="font-family:'Times New Roman', serif">Claimant.</span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Claimant’s Wife or </span><span style="font-family:'Times New Roman', serif">Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">If</span><span style="font-family:'Times New Roman', serif; font-style:italic"> </span><span style="font-family:'Times New Roman', serif">you own or have an interest in more than one house, which of those mentioned above do you live in?</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Is any of your property subject to a mortgage or other encumbrance?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, state clearly which property is en</span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.05pt">cumbered; also the name and address </span><span style="font-family:'Times New Roman', serif">of the person to whom the money is </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">owing and the amount of the debt.)</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you a share or interest in any other property?</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">What is the nature and value of such share or interest?</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own any horses, cattle, sheep, or other live stock, or any vehicles, implements, &amp;c.?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Give particulars and value.)</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any interest in a deceased estate, or under any settlement, deed of gift, or deed or declaration of trust?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Give full particulars.)</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any money in any bank, savings bank, building society, or other institution, or any money in hand?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">(If to, give details as to amounts, name and </span><span style="font-family:'Times New Roman', serif">address of bank, &amp;c.)</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">It your life insured?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.3pt">(If so, state name of company, policy number, </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.15pt">amount, and age at which amount pay</span><span style="font-family:'Times New Roman', serif">able; also state by whom premiums are paid.)</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.42%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own any Government or other bonds or stock or industrial shares, or have you lent money to any person on mortgage or in any other manner?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, give particulars.)</span></p></td><td style="width:16.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:16.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td rowspan="2" style="width:66.56%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Q</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">uestions</span><span style="font-family:'Times New Roman', serif">.</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">ANSWERS.</span></p><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">(In The Case of Husband Persons, Information is Required Concerning Both Husband and Wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:18.22%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning </span><span style="font-family:'Times New Roman', serif">Claimant.</span></p></td><td style="width:15.22%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; letter-spacing:-0.25pt">Information concerning </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.2pt">Claimant’s Wife or </span><span style="font-family:'Times New Roman', serif">Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:66.56%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any real or personal property not elsewhere disclosed in this statement?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">, </span><span style="font-family:'Times New Roman', serif">give particulars.)</span></p></td><td style="width:18.22%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.22%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.56%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you during the past five years transferred or otherwise disposed of money or other property of any kind?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, give particulars how disposed of and </span><span style="font-family:'Times New Roman', serif; letter-spacing:-0.1pt">to whom, and the value received therefor</span><span style="font-family:'Times New Roman', serif">.)</span></p></td><td style="width:18.22%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.22%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:66.56%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:18pt; margin-bottom:0pt; text-indent:-18pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">At what Post Office do you desire your pension, if granted, to be paid?</span></p></td><td style="width:18.22%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:15.22%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>

Signature of claimants...........................................

_______

Declaration.

* Name of Claimant.

† Residents and occupation.

I,*.....................................................................

of†.....................................................................

.......................................................................

the above-named claimant for an Invalid Pension under the Invalid and Old-age Pensions Act 1908-1938 do hereby declare that the contents of my pension claim on which this declaration is indorsed are true and correct in every particular.

<table cellspacing="0" cellpadding="0" style="margin-left:36pt; margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:143.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Declared at...........................</span></p></td><td rowspan="2" style="width:1.8pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><img src="image.001.png" width="12" height="26" alt="Brace grouping details of declaration"></p></td><td style="width:141.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr><td style="width:143.7pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">the.........day of.........19</span></p></td><td style="width:141.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Signature of Declarant.)</span></p></td></tr></tbody></table>

Before me—

‡§..................................

..............................

‡ The person before whom this declaration is made to sign here and add the title by which he takes the declaration, such as “Postmaster” &c.

§ The declaration may be made before any of the following persons:—A postmaster or postmistress, or person in charge of a post office, a permanent officer of the Postmaster-General’s Department whose duties include the payment of invalid or old-age pensions, a police, stipendiary, or special magistrate of the Commonwealth or of a State, a justice of the peace, a barrister or solicitor, a State school head-teacher, an officer of the Department of Trade and Customs, a member of the police force of the Commonwealth or of a State, a legally qualified medical practitioner, a notary public, a commissioner for affidavits, a commissioner for declarations, a registrar under the Invalid and Old-age Pensions Act 1908-1933, a minister of religion, an officer of the Commonwealth Department of the Treasury, a councillor of any municipality or shire, or a member of the Parliament of the Commonwealth or of any State.”.

Forms 41 and 42 repealed.

3. Forms 41 and 42 in the Invalid and Old-age Pensions Regulations are repealed.

______________________

By Authority: L. F Johnston, Commonwealth Government Printer, Canberra.