REGULATIONS UNDER THE INVALID AND OLD-AGE PENSIONS ACT 1908-1926.
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 1908-1926, to come into operation forthwith.
Dated this seventeenth day of December, 1926.
STONEHAVEN,
Governor-General.
By His Excellency’s Command,
THOS. W. CRAWFORD,
for Treasurer.
INVALID AND OLD-AGE PENSIONS REGULATIONS.
Part I.—Introductory.
Short title.
These Regulations may be cited as the Invalid and Old-age Pensions Regulations.
Parts.
These Regulations are divided into Parts, as follows:—
Part I.—Introductory.
Part II.—Lodging, Investigation, and Determination of Claims.
Part III.—Payment of Pensions.
Part IV.—Miscellaneous.
Declaration by officers.
3. The declaration to be made by the Commissioner, the Assistant Commissioner and the Deputy Commissioners, under section 13 of the Act, shall be in accordance with Form 1.
Assistance to claimants.
4. All officers of the Public Service of the Commonwealth shall, so far as is consistent with their duties, give all reasonable assistance to claimants in the preparation of pension claims.
Declarations.
(1) Declarations under these Regulations and declarations under the Act, other than declarations provided for under section 13, may be made before any of the following persons:—
A postmaster or postmistress, or person in charge of a post office, 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
C.15061.—Price 1s.
medical practitioner, a notary public, a commissioner for affidavits, a commissioner for declarations, a registrar, 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.
(2) If any person wilfully makes any false statement in any declaration provided for under these Regulations he shall, if subject to no higher penalty under the Act, be liable to a penalty not exceeding One hundred pounds.
Part II.—Lodging, Investigation, and Determination of Claims.
Pension claims.
Any person claiming a pension shall deliver or send to the Registrar of the district in which he resides—
(1) a pension claim in accordance with Form 2, if claim is made for an Old-age Pension, or a pension claim in accordance with Form 3 if claim is made for an Invalid Pension;
(2) a declaration, in accordance with Form 4, made by a person acquainted with the claimant; and
(3) an identification card in accordance with Form 5.
Record of claims.
Unless otherwise directed by the Commissioner, every Registrar shall keep a record, in accordance with Form 6, of pension claims received by him.
Investigation by Registrar.
On receipt of a claim the Registrar shall examine the claim together with any other papers in the case. If it appears to him that the evidence on any material point is insufficient for a just determination of the claim, he shall, in accordance with Form 7 or 8 or 9, or in ordinary letter-form, cause to be made such further investigations as appear to him desirable. He may also request the police to make a report in accordance with Form 10:
Provided that in any case in which it appears that documentary evidence as to the claimant’s age is not easily obtainable, it shall not be necessary for the Registrar to make further inquiries on the point if he believes that the age qualification will be obvious when the claimant appears before the Magistrate.
Reference to Magistrate.
The Registrar shall ascertain the time and place at which a Magistrate will investigate the claim, and shall send to the claimant and to the Magistrate notices in accordance with Forms 11 and 12 respectively. He shall also refer the claim to the Magistrate in accordance with Form 13. Notice in accordance with Form 12 need not be sent if the Registrar is aware that the Magistrate does not require such notice. If the Registrar is aware that, by reason of physical disability, or the distance of the claimant’s residence from the place of investigation, or for other sufficient cause, the claimant cannot reasonably be expected to attend, the notice in accordance with Form 11 need not be sent, and in that case a note shall be made on Form 13. If the Registrar will not be in attendance at the place of investigation when claims are to be investigated by the Magistrate, he shall take steps to place the claims and all the papers connected therewith in the hands of the Magistrate before the time for the investigation.
Delay in investigation.
If for any reason a Magistrate cannot investigate any claim within a reasonable time the Registrar shall inform the Deputy Commissioner. The information shall be conveyed to the Deputy Commissioner by telegraph if the Registrar deems it advisable.
Examination by Medical Referee.
When it is necessary that a claimant be examined by a Commonwealth Medical Referee the Registrar shall notify the claimant and the Medical Referee in accordance with Forms 14 and 15 respectively. The result of the examination shall be communicated by the Medical Referee to the Registrar in accordance with Form 16.
Calculation of pension.
(1) In calculating the maximum pension which may be recommended, there shall be deducted from Eighty-four pounds ten shillings the amount of the claimant’s income, including income from accumulated property, and from the balance remaining, or from Fifty-two pounds, whichever is lower in amount, there shall be deducted an amount, calculated as directed in sub-section (2) of section 24 of the Act, in respect of the net capital value of the claimant’s accumulated property.
(2) In the case of a permanently blind claimant the amount of pension which may be recommended shall be calculated by deducting from Two hundred and twenty-one pounds or from such other amount as is declared by any Act or by any authority constituted under an Act to be a basic wage for the portion of the Commonwealth in which the claimant resides, the amount of the income of the claimant and of the claimant’s wife or husband, as the case may be, including income from accumulated property, and from the balance remaining, or from Fifty-two pounds, whichever is lower in amount, there shall be deducted an amount, calculated as directed in sub-section (2) of section 24 of the Act, in respect of the net capital value of the claimant’s accumulated property.
Section 25 of Act not to apply in certain cases.
13. If for any special reason the Commissioner is of opinion that paragraph (d) of section 25 of the Act should not apply in any particular case, he may direct that it shall not apply.
Sale of home.
Where a claimant or pensioner sells his home on terms and purchases another home also on terms and uses instalments received by him from the sale of the first mentioned home to pay the purchase money on the last mentioned home, the amount of the balance due from time to time on the last mentioned home may, in assessing the net capital value of the accumulated property of the claimant or pensioner, be allowed as a deduction from the amount due to the claimant or pensioner in respect of the sale of the first mentioned home.
Recommendation by Magistrate.
The Magistrate shall make a recommendation in accordance with Form 17 if the claim is for an Old-age Pension, or Form 18 if the claim is for an Invalid Pension. In any case in which he postpones an investigation, he shall, on the claim, record as proved all matters as to which he is satisfied.
Return of papers to Registrar, &c.
16. (1) When a Magistrate has recommended the admission or rejection of a pension claim, he shall forward to the Registrar all the papers relating to the claim, together with the notes of evidence taken at the investigation of the claim.
(2) Subject to paragraph (3) of this regulation, the Registrar shall send to the Deputy Commissioner the papers and the evidence received from the Magistrate together with the identification card.
(3) In cases where the recommendation by the Magistrate for the rejection of the claim shows that no material point has been disproved, bat that some material points have not been proved or have not been sufficiently proved, the Registrar shall retain the papers for one month, or until he has received from the claimant a notice in accordance with Form 19 of intention to adduce fresh evidence, in which case the matter shall be dealt with as prescribed by section 32 of the Act. if a notice in accordance with Form 19 has not been received, or if the notice has been received and the case has been dealt with as directed, the Registrar shall forthwith forward the papers, evidence and identification card to the Deputy Commissioner,
Appeal to Minister
A claimant may, at any time after the date of the recommendation by the Magistrate for the rejection of his claim, appeal to the Minister in respect of matters found by the Magistrate to be disproved. The appeal shall be in accordance with Form 20.
Rehearing of claim.
Any request of the Commissioner or a Deputy Commissioner for a re-hearing of a pension claim previously admitted or rejected shall be addressed to a Registrar, who shall, in accordance with Forms 11 and 12, notify the claimant or pensioner and the Magistrate. For this purpose verbal alterations in those forms may be made. In connexion with the re-hearing the Registrar shall have the same powers as in connexion with the original claim.
Advice of determination of claim.
19. The determination of the Commissioner or Deputy Commissioner in relation to any claim shall be communicated to the claimant in accordance with Form 21 or Form 22.
Income and property statement.
(1) The statement relating to income and property which a pensioner may be required to furnish under sub-section (1) of section 38 of the Act shall be in accordance with Form 23. The Deputy Commissioner may request a postmaster to deliver Form 23 to any pensioner from whom a statement of income and property is required. The request to the postmaster shall be in accordance with Form 24.
(2) Where it is necessary to ask the police for a report regarding income and property statements, the request to the police shall be in accordance with Form 25.
Part III.—Payment of Pensions.
Pension certificate.
On the grant of a pension, a pension certificate in accordance with Form 26, which shall show the dates on which instalments of pension are payable, together with an identification card in accordance with Form 5 shall be forwarded to a postmaster or other officer authorized to make payment of the pension. The postmaster or other officer shall retain the identification card, and shall deliver the certificate to the pensioner in accordance with departmental instructions:
Provided that where money is payable to a pensioner while he is an inmate of a benevolent asylum or hospital the pension certificate shall be in such form as is directed by the Commissioner and it shall not be necessary to prepare an identification card in accordance with Form 5.
Authority for payment of pension.
The possession of any identification card shall be regarded as the authority of the postmaster or other officer to make payment of the pension thereon described:
Provided that, as regards the method of paying, the postmaster or other officer shall follow such instructions as are from time to time issued by the Commissioner:
Provided also that, if so instructed by the Commissioner or Deputy Commissioner, the postmaster or other officer shall not make payment of the pension.
Pension fortnight.
(1) The fortnights in respect of which instalments of pensions are payable shall in every case commence on a Thursday and end on a Wednesday. The first of such fortnights shall be deemed to have commenced on Thursday, 1st July, 1909, and all subsequent fortnights shall be calculated accordingly up to and including the fortnight which commenced on 21st April, 1921. The next succeeding fortnight shall be deemed to have commenced on 28th April, 1921, and all succeeding fortnights shall be calculated as from that date:
Provided that the amount of pension payable in respect of the fortnight which commenced on 28th April, 1921, shall be not more than one-half of the usual fortnightly instalment.
(2) Every such fortnight shall be known as a “pension fortnight,” and the first day of every “pension fortnight” shall be known as “Pension Thursday,”
Due date of instalments.
(1) The due date of each instalment of pension granted prior to 1st December, 1910, shall be the first day following the pension fortnight for which the instalment was payable. The due date of each instalment of pension granted on and after 1st December, 1910, shall be the first day of the pension fortnight for which the instalment is payable.
(2) Any moneys due to a pensioner on his discharge from a hospital or a benevolent asylum shall be deemed to be one instalment, and the due date thereof shall be the day of the pensioner’s discharge from the institution.
Duplicate pension certificate.
If a pensioner loses his pension certificate, he may make application, in accordance with Form 27, to the Deputy Commissioner for a duplicate certificate; and the Deputy Commissioner, if he issues a duplicate, shall notify the postmaster or other officer who is authorized to pay the pension. The duplicate shall bear across its face the word “duplicate,” together with a note in writing, under the hand of the Deputy Commissioner, stating the date on which the duplicate is issued.
Change of place of payment.
26. (1) If a pensioner desires to permanently leave the place at which he resides to reside in another place, he may make application in Form 28 to the postmaster or other officer authorized to pay his pension, and if the postmaster or other officer is satisfied that the request is a reasonable one, he shall make a note on the pensioner’s identification card and on the pension certificate, as follows:—”Payment to be made in future at .” The postmaster or other officer shall also make a note on the identification card as follows:— “The last payment made at this office was due on ‘Pension Thursday,’ the 19 ,” and shall add his signature, and shall forward
the identification card by post to the office to which payment is to be transferred. Upon receipt of the identification card, the postmaster or other officer at the office to which payment has been transferred shall, subject to any instructions issued by the Commissioner or Deputy Commissioner, make payment of the pension as it falls due.
(2) The application in accordance with Form 28 shall, if approved by the postmaster or other officer, be transmitted to the Deputy Commissioner.
(3) A pensioner shall not, without the permission of the Deputy Commissioner, be allowed to change the office of payment more than twice in any calendar year.
Receipt for instalment of pension.
The receipt given by a pensioner shall be in accordance with Form 29. If the payee is a person other than the pensioner, the payee shall give a receipt in accordance with Form 30.
Payment to be made only to pensioner or warrantee.
Payment of pension shall not be made to any person other than the pensioner unless such person is the holder of a warrant under section 43 or 44 of the Act, and certifies that he has seen the pensioner within the preceding three months:
Provided that, if approved by the Deputy Commissioner, payment may be made to the holder of a warrant who has not seen the pensioner within the preceding three months.
Payment of forfeited instalments.
In the event of any instalment being forfeited under section 40 of the Act, the pensioner, or other person being the holder of a warrant, may make application, in accordance with Form 31, to the Registrar of the district in which the pension is payable, for payment of the forfeited instalment. The waiver of forfeiture shall be in accordance with Form 32, and shall not be granted in any case in which the application has not been made within sixty days after the expiration of the period during which the instalment was payable.
Warrants.
(1) Where a pensioner desires payment of his pension to be made to some other person on his behalf, he may make application to the Registrar, in accordance with Form 33, for the issue of a warrant authorizing payment to such other person. The application shall bear the proposed payee’s consent in writing and shall disclose the names of all pensioners on whose behalf the proposed payee already holds warrants together with such other particulars as are directed by the Commissioner. The application shall be forwarded to the Deputy Commissioner by the Registrar.
(2) The warrant shall be in accordance with Form 34 and shall continue in force until a date to be named therein or until otherwise ordered by the Deputy Commissioner.
(3) Where the Deputy Commissioner considers it expedient to do so, he may issue a warrant in accordance with Form 34 notwithstanding that an application in accordance with Form 33 has not been made.
Payment under warrant or waiver of forfeiture.
31. Whenever any instalment is payable under a warrant or waiver of forfeiture, the pension certificate, together with the warrant or waiver, shall be produced by the pensioner or other payee at the time of payment.
Pensioner in benevolent asylum, &c.
32. (1) When any pensioner becomes an inmate of any benevolent asylum, hospital, or asylum for the insane, the Secretary of other officer of the benevolent asylum, hospital, or asylum for the insane, shall forthwith forward a notification in accordance with Form 35 to the postmaster or other officer authorized to pay the pension.
(2) When any pensioner becomes an inmate of a benevolent asylum, payment of his pension shall be suspended and the Commissioner or Deputy Commissioner shall direct a Magistrate to re-hear the claim. If as a result of the re-hearing the Commissioner or Deputy Commissioner is of opinion that the pensioner intends to remain permanently in the benevolent asylum he shall cancel the pension and shall authorize the payment to the inmate of a pension at the rate of Four shillings per week. If the Commissioner or Deputy Commissioner is of opinion that the pensioner does not intend to remain permanently in the benevolent asylum the pension shall remain suspended, but when the pensioner has remained an inmate for a period of twenty-eight days he shall upon the expiration of that period and so long thereafter as he remains an inmate be entitled to a pension at the rate of Four shillings per week.
Discharge of pensioner from benevolent asylum, &c.
(1) When any pensioner is discharged from a benevolent asylum, hospital, or asylum for the insane, the Secretary or other officer of the benevolent asylum, hospital, or asylum for the insane shall forthwith forward a notification in accordance with Form 36 to the postmaster or other officer authorized to pay the pension.
(2) On receipt of notice of discharge in accordance with Form 36 the postmaster or other officer may resume payment of the pension, and in a case in which the pensioner has been an inmate of the benevolent asylum or hospital for a period of not more than four weeks he shall be entitled to payment of his pension for the whole of that period; but in a case in which the pensioner has been an inmate for a longer period he shall in respect of the period during which he was an inmate be entitled on discharge to payment of his pension for the first twenty-eight days of his stay in the institution:
Provided that in any case in which a pensioner has been an inmate of a benevolent asylum, the postmaster or other officer shall not make any payment unless so directed by the Commissioner or Deputy Commissioner.
(3) In any case in which a pensioner has been an inmate of a benevolent asylum, hospital, or asylum for the insane for a period of more than four weeks the calculation of the amount of pension payable on his discharge shall be made in accordance with Form 37.
Alteration in rate of pension
34. (1) Where any alteration is made in the rate of a pension the Deputy Commissioner shall notify the postmaster or other officer in accordance with Form 38 and the postmaster or other officer shall thereupon make payment of the pension at the altered rate.
(2) Notice of the alteration in accordance with Form 39 shall also be forwarded by the Deputy Commissioner to the pensioner or other person authorized to receive payment.
Part IV —Miscellaneous.
Death of pensioner.
35. (1) Whenever the death of any person is reported to a Registrar of Deaths for registration, the Registrar of Deaths shall inquire whether the deceased was a pensioner, and the person reporting the death shall state, to the best of his knowledge, whether the deceased was a pensioner or not. If the deceased was a pensioner, the Registrar of Deaths shall send to the Deputy Commissioner a notice of the death in accordance with Form 46.
(2) In this Regulation Registrar of Deaths means any Commonwealth or State officer charged with the duty of registering deaths.
Pension due at death of pensioner.
Any undrawn instalment of a pension due at the date of a pensioner’s decease, if applied for within six months after the decease, may be paid to the person who in the opinion of the Deputy Commissioner is best entitled to receive it.
Repeal.
The Invalid and Old-age Pensions Regulations (being Statutory Rules 1915 No. 254 as amended by Statutory Rules 1916 No. 278, Statutory Rules 1918 No. 285, Statutory Rules 1925 No. 176 and Statutory Rules 1926 No. 47) are repealed as from the commencement of these Regulations.
Form 1.
COMMONWEALTH OF AUSTRALIA.
———
The Invalid and Old-age Pensions Act 1908-1926. Section 13.
———
DECLARATION.
I, do solemnly and sincerely promise and declare that I will, according to law and to the best of my knowledge and ability, discharge the duties of the office of* under the above-named Act.
Declared at this day of 19 before me
†Justice of the Peace, or
Commissioner for Affidavits, or
Commissioner for Declarations
* Fill in nature of office.
† Strike out what is inapplicable.
———
Form 2.
COMMONWEALTH OF AUSTRALIA.
———
The Invalid and Old-age Pensions Act 1908-1926.
———
OLD-AGE PENSION CLAIM.
Attention is directed to the following:—
Section 27, sub-section 4 of the Act reads:—
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: £100 or imprisonment for one year.
*Name of Claimant in full.
† Residence (Postal Address).
‡ Occupation.
I,
of†
‡
hereby claim an Old-age Pension under the above Act.
I affirm that, in respect of an Old-age Pension, I have all the qualifications and requirements and have not any of the disqualifications under the Invalid and Old-age Pensions Act 1908-1926.
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.
Questions.
Answers.
Where were you born ?(Name the place and country.)
(If you have documentary proof of age, it should (if practicable) be attached to this page.)
When were you born ?(Give exact date if possible.)
If not born in Australia, when did you first arrive in Australia ?
From what port did you sail for Australia †
What was the name of the ship ?
At what port did you land ?
Were you a passenger or immigrant or member of crew ?(State which.)
Questions.
Answers.
Since you first arrived in Australia have you visited New Zealand or any other country?
If so, how long altogether were you away from Australia ? (Give full particulars, including dates of departure from, and return to, Australia.)
Are you single, married, widow, or widower ?(State which.)
If you are married, what is the full name of your husband or wife ?
Where and when were you married ?(Give exact date if possible.)
If you are a widow or married woman, what was your maiden name ?
What are the names, dates of birth, places of birth, &c., of all your children ?—
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:42pt"><td style="width:30.02%; 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-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Names of Children.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Dates of Birth.</span></p></td><td colspan="3" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Places of Birth. (Show name of State as well as Place.)</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-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Places where Births Registered.</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:48.3pt"><td style="width:30.02%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><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; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="3" 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; font-size:10pt"><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; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Questions—</span></p></td><td colspan="3" style="border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers—</span></p></td><td style="border-top:0.75pt solid #000000; vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What are the names and addresses of your children now living ?</span></p></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you, or has your wife or husband, at any time applied for a War Pension ? If so, when and where?</span></p></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you, or has your wife or husband, at any time applied for an Invalid or Old-age Pension ? If so, when and where ?</span></p></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Were you born a British subject?</span></p></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="4" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Are you a naturalized British subject? if so, when and where were you naturalized?</span></p><p style="margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Papers or other evidence must be produced to the Magistrate.)</span></p></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="border-bottom:0.75pt solid #000000; vertical-align:top"></td><td style="border-bottom:0.75pt solid #000000; vertical-align:top"></td></tr><tr style="height:45.6pt"><td colspan="2" rowspan="2" style="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; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Questions.</span></p></td><td colspan="7" 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; font-size:10pt"><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; font-size:10pt"><span style="font-family:'Times New Roman', serif">(In the case of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:44.25pt"><td colspan="3" 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td colspan="4" 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant’s Wife or Husband.</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><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:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If earning, give name and address of employer.)</span></p></td><td colspan="3" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="4" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">By whom were you employed during the last twelve months?</span></p></td><td colspan="3" style="border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="4" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did you earn during the last twelve months?</span></p></td><td colspan="3" style="border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="4" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Did you receive board or lodging besides money wages?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If not received during the whole of the last twelve months state how long received)</span></p></td><td colspan="3" style="border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="4" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did each of your children </span><span style="font-family:'Times New Roman', serif; font-style:italic">not living with you </span><span style="font-family:'Times New Roman', serif">contribute to your support during the last twelve months?</span></p></td><td colspan="3" style="border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="4" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:136.7pt"></td><td style="width:77.4pt"></td><td style="width:29.15pt"></td><td style="width:24.05pt"></td><td style="width:66.05pt"></td><td style="width:15.75pt"></td><td style="width:95.75pt"></td><td style="width:5.75pt"></td><td style="width:4.85pt"></td></tr></tbody></table>
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:44.25pt"><td rowspan="2" style="width:47.02%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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; font-size:10pt"><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; font-size:10pt"><span style="font-family:'Times New Roman', serif">(In the case of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:28.6%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td style="width:24.38%; 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-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><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:47.02%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did each of your children </span><span style="font-family:'Times New Roman', serif; font-style:italic">living with you </span><span style="font-family:'Times New Roman', serif">contribute towards the maintenance of the home during the last twelve months?</span></p></td><td style="width:28.6%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><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:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature of the same, and what profit did you make during the last twelve months?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Has any one agreed to maintain you in whole or in part or to make any payments to you in consideration of property you have transferred?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">During the last twelve months did you receive free board or free lodging or both?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State which received, and for how long received)</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><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:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Reply should include rents, after deduction of repairs, &c., dividends from banks or companies, interest on money lent or in banks, and any other income. The nature and amount of the income in each case should be stated.)</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What house or land property do you own?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Where is it situated?</span><span style="width:121.94pt; font-family:'Lucida Console', monospace; display:inline-block">....................</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature of the title?</span><span style="width:82.79pt; font-family:'Lucida Console', monospace; display:inline-block">.............</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the full capital value?</span><span style="width:84.18pt; font-family:'Lucida Console', monospace; display:inline-block">.............</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Where a valuation of the property has been made for any local authority, the last notice of assessment, or a letter from an official of such local authority, stating the capital value as assessed, must be sent, pinned to this page, to the Registrar of Pensions.)</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:9pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If you own only one house, do you live in it?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td rowspan="2" style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If you own more than one house, which of those mentioned above do you live in?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is any of the property mortgaged or otherwise encumbered?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state amounts, also names, and addresses of the persons to whom the mortgages or encumbrances have been granted.)</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you a share or interest in any other property?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature and value of such property?</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:47.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Do you own any horses, cattle, sheep, or other live stock?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Give particulars and value.)</span></p></td><td style="width:28.6%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.38%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><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:45.15pt"><td rowspan="2" style="width:47%; 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; font-size:9pt"><span style="font-family:'Times New Roman', serif">Q</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">uestions.</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; font-size:9pt"><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; font-size:9pt"><span style="font-family:'Times New Roman', serif">(In the case of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:27.44%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td style="width:25.56%; 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-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:9pt"><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:47%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Do you own any furniture, vehicles, &c.?</span></p><p style="margin-left:28.8pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(State nature and value of each separately.)</span></p></td><td style="width:27.44%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left: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:25.56%; border-top:0.75pt solid #000000; border-left: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:47%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; 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 financial institution?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, state names, addresses, and amounts.)</span></p></td><td style="width:27.44%; border-right:0.75pt solid #000000; border-left: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:25.56%; border-left: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:47%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Is your life assured?</span></p><p style="margin-left:28.8pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(If so, state name of company, policy number, amount, and age at which amount payable; also state by whom premiums are paid.)</span></p></td><td style="width:27.44%; border-right:0.75pt solid #000000; border-left: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:25.56%; border-left: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:47%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Have you any money or property not previously disclosed?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(The reply should include information as to money in hand, money lent, debentures, stock, bank or mining shares, or any other property.)</span></p></td><td style="width:27.44%; border-right:0.75pt solid #000000; border-left: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:25.56%; border-left: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:47%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">What property have you parted with during recent years?</span></p></td><td style="width:27.44%; border-right:0.75pt solid #000000; border-left: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:25.56%; border-left: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:47%; 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:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">At what post office do you desire pension, if granted, to be paid?</span></p></td><td style="width:27.44%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom: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:25.56%; 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.
I,* of†
do hereby declare that I am the claimant for an Old-age Pension under the Invalid and Old-age Pensions Act 1908-1926, and that the contents of my pension claim on which this declaration is endorsed are true and correct in every particular.
Declared atthe day of 19
(Signature of Declarant.)
Before me,
§ ‡
* Name of Claimant.
† Residence and occupation.
‡ 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 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 1908-1926, 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.
COMMONWEALTH OF AUSTRALIA. Form 3.
———
The Invalid and Old-age Pensions Act 1908-1926.
INVALID PENSION CLAIM.
Attention is directed to the following:—
Section 27, sub-section 4, of the Act reads:—
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: £100 or imprisonment for one year.
*Name of Claimant in full.
†Residence (Postal Address.)
‡ Occupation.
I *
of†
‡
hereby claim an Invalid Pension under the above Act.
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 Invalid and Old-age Pensions Act 1908-1926.
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.
———
Questions.
Answers.
Where were you born?(Name the place and country.)
When were you born?(Give exact date if possible.)
If not born in Australia, when did you first arrive in Australia?
From what port did you sail for Australia?
What was the name of the ship?
At what port did you land?
Were you a passenger or immigrant or member of crew?(State which.)
Since you first arrived in Australia have you visited New Zealand or any other country?
If so, how long altogether were you away from Australia? (Give full particulars, including dates of departure from, and return to, Australia).
Are you single, married, widow, or widower?(State which.)
If you are married, what is the full name of your husband or wife?
Where and when were you married?(Give exact date if possible.)
If you are a widow or married woman, what was your maiden name?
Have you at any time applied for an Invalid or Old-age Pension? If so, when, and where?
Have you at any time applied for a War Pension? If so, when, and where?
Were you born a British subject?
Are you a naturalized British subject? If so, when and where were you naturalized?(Papers or other evidence must be produced to the Magistrate.)
What are the names and addresses of your children now living?
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:44.25pt"><td rowspan="2" style="width:46.02%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(In the case of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:27.94%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td style="width:26.04%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><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:46.02%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much per week are you earning now?</span></p></td><td style="width:27.94%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If earning, give name and address of employer.)</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">By whom were you employed during the last twelve months?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did you earn during the last twelve months?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Did you receive board or lodging besides money wages?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If not received during the whole of the last twelve months, state how long received)</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did each of your relatives (namely, father, mother, husband, wife, or children) </span><span style="font-family:'Times New Roman', serif; font-style:italic">not living with you</span><span style="font-family:'Times New Roman', serif"> contribute to your support during the last twelve months?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did each of your relatives (namely, father, mother, husband, wife, or children) </span><span style="font-family:'Times New Roman', serif; font-style:italic">living with you</span><span style="font-family:'Times New Roman', serif"> contribute towards the maintenance of the home during the last twelve months?</span></p></td><td style="width:27.94%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><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:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature of the same, and what profit did you make during the last twelve months?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Has any one agreed to maintain you in whole or in part or to make any payments to you in consideration of property you have transferred?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">During the last twelve months did you receive free board or free lodging or both?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State which received, and for how long received.)</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What other income have you received during the last twelve months?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Reply should include rents, after deduction of repairs, &c., dividends from banks or companies, interest on money lent or in banks and any other income. The nature and amount of the income in each case should be stated.)</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><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></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state full particulars.)</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you ever received compensation on account of accident or ill health?</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:46.02%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state full particulars.)</span></p></td><td style="width:27.94%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.04%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><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:48.75pt"><td rowspan="2" style="width:48.86%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(In the case of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:44.25pt"><td style="width:26.06%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td style="width:25.08%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><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:48.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What house or land property do you own?</span></p></td><td style="width:26.06%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Where is it situated?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature of the title?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the full capital value?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Where a valuation of the property has been made for any local authority, the last notice of assessment or a letter from an official of such local authority, stating the capital value as assessed, must be sent, pinned to this page, to the Registrar of Pensions.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If you own only one house, do you live in it?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If you own more than one house, which of those mentioned above do you live in?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is any of the property mortgaged or otherwise encumbered?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state amounts, also names and addresses of the persons to whom the mortgages or encumbrances have been granted.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you a share or interest in any other property?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature and value of such property?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Do you own any horses, cattle, sheep, or other live stock?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Give particulars and value.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Do you own any furniture, vehicles, &c.?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State nature and value of each separately.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you any money in any bank, savings bank, building society or other financial institution?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state names, addresses, and amounts.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is your life assured?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state name of company, policy number, amount, and age at which amount payable; also state by whom premiums are paid.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you any money or property not previously disclosed?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(The reply should include information as to money in hand, money lent, debentures, stock, bank or mining shares, or any other property.)</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What property have you parted with during recent years?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:48.86%; 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:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">At what post office do you desire pension, if granted, to be paid?</span></p></td><td style="width:26.06%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.08%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>
Signature of Claimant
DECLARATION,
I*
of†
do hereby declare that I am the claimant for an Invalid Pension under the Invalid and Old-age Pensions Act 1908-1926, and that the contents of my pension claim on which this declaration is indorsed are true and correct in every particular.
Declared atthe day of 19
(Signature of Declarant.)
Before me,
§ ‡
* Name of Claimant.
† Residence and occupation.
‡ 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 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 1908-1926, 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.
————
Form 4.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
DECLARATION BY PERSON WHO HAS KNOWN CLAIMANT FOR A LENGTHENED PERIOD.
attention is directed to the following:—
(a) Every claimant is expected to send to the Registrar of Pensions a declaration made by a person who has known claimant for a period of at least 20 years in the case of a claimant for an Old-age Pension, and 5 years in the case of a claimant for an Invalid Pension, but if no such person can be found the declaration may be made by a person of shorter acquaintance.
(b) Declarant should not be a relative of claimant.
(c) Section 49 (d) of the Act reads:—
No person shall by any wilfully false statement or representation aid or abet any person in obtaining or claiming a pension certificate or pension, or instalment of a pension. Penalty—£100, or six months’ imprisonment.
Name, Address, and Occupation of Claimant for Pension.
I, do solemnly and sincerely declare that the (Name, address, and occupation of declarant.)
information given in this form, in relation to the above-named claimant for a pension, is to the best of my knowledge and belief, true and correct in every particular.
How long have you known claimant?In what places have you known claimant?Are you related to claimant?Has the claimant been absent for any considerable period from Australia?(If so, give particulars.)What are the incidents which assist you in recollecting the length of your acquaintance with claimant?How frequently have you seen claimant during the last three years?What is the nature and the value of property of all kinds which you believe claimant to be possessed of?(Reply to this should give information as to land, houses, money in bank, money lent, money in hand, furniture, live stock, harness, &c. The value of each class of property should be separately stated.)(If room insufficient here, write on back.)
How has claimant been maintained latterly?(Give full particulars.)If claimant is applying for an Invalid Pension—In your opinion, is claimant permanently incapacitated for work, and on what do you base your opinion?If claimant is married—What income and property has claimant’s wife or husband?
Declared at this day of 19before me,*†
Signature of Declarant.
* 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 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 1908-1926, 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.
——
Form 5.Pension Certificate No.Pensioner’s NamePension at the rate of fortnightly granted, payable atThe Pensioner was first entitled to payment on “Pension Thursday,” the 19 for the fortnight commenced on that date.Deputy Commissioner.Date
Payment to be made in future at The last payment made at this office was due on “Pension Thursday,” the
19 .
Signed
Postmaster at Date
Payment to be made in future at The last payment made at this office was due on “Pension Thursday,” the
19 .
Signed
Postmaster at Date
Payment to be made in future at The last payment made at this office was due on “Pension Thursday,” the
19 .
Signed
Postmaster at Date
This Card to be forwarded by the Registrar to the Deputy Commissioner who, if pension approved, will send it to a Postmaster or other Paying Officer. The last-named must retain the Card as his authority for paying pension. [The Card should not be Folded.]
<table cellspacing="0" cellpadding="0" style="width:100%; margin-left:3.65pt; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td rowspan="9" style="width:9.04%; height:1pt; margin-left:auto; writing-mode:tb-rl; padding-right:2pt; padding-left:2pt; vertical-align:top; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:1pt; margin-left:auto; writing-mode:tb-rl; overflow:hidden"><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Form 5.</span></p><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Particulars for identification of pensioner.</span></p></div></td><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Name of Claimant in full</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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 rowspan="9" style="width:6.94%; height:1pt; margin-left:auto; writing-mode:tb-rl; padding-right:2pt; padding-left:2pt; vertical-align:top; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:1pt; margin-left:auto; writing-mode:tb-rl; overflow:hidden"><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif; font-style:italic">Rate of Pension to be paid is shown on other side.</span></p></div></td></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Date of Birth</span></p></td><td style="width:17.78%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">Place of Birth</span></p></td><td style="width:26.68%; padding-right:2pt; 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></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Postal Address</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Last Occupation</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Number of Children</span></p></td><td style="width:17.78%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:29.5pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">of whom</span></p></td><td style="width:26.68%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">are living</span></p></td></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Name of Claimant’s Father</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Maiden Name of Claimant’s Mother</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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></tr><tr style="height:1pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Signature of Claimant</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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></tr><tr style="height:36.9pt"><td style="width:39.56%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:21.6pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(or his witnessed mark).</span></p></td><td style="width:17.78%; padding-right:2pt; 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:26.68%; padding-right:2pt; 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></tr></tbody></table>
Registrar
C.15061.—2
Form 6.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
DISTRICT REGISTER OF PENSION CLAIMS.
Date of Receipt of Claim.
Surname.
Christian Name.
Occupation.
Address.
Date when finally dealt with by Magistrate.
Nature of Magistrate’s Recommendation.
Date when Claim and Magistrate’s Recommendation sent to Deputy Commissioner.
Short Particulars of Income and Property as accepted by Magistrate.
Remarks.
————
Form 7.
COMMONWEALTH OF AUSTRALIA.
————
The Invalid and Old-age Pensions Act 1908-1926.
CONFIDENTIAL REPORT—GENERAL.
Full Name of Claimant for Pension
Address of Claimant
Section 28 (sub-section 2) of the Act reads:—
“The Registrar may require any person, whom he believes to be in a position to do so, to furnish to him, for submission to the Magistrate, a confidential report as to the circumstances or the financial transactions of any claimant or pensioner or of any relatives of a claimant or pensioner; and any person who, on being required to do so by the Registrar, fails to furnish a report within a reasonable time, or furnishes a report containing any statement which is untrue in any particular, shall be guilty of an offence.” Penalty: One hundred pounds or six months’ imprisonment.
——
From the Registrar of Pensions at
To
The above-named is a claimant for a pension, and I have to request that you will be so good as to inform me as follows:—
It is requested that your reply be written hereunder.
Registrar.
Date
From
To the Registrar of Pensions at
Signed
Date
Form 8.
COMMONWEALTH OF AUSTRALIA.
The Invalid and Old-age Pensions Act 1908-1926.
——
CONFIDENTIAL REPORT—BANK.
From the Registrar of Pensions at
To the Manager, Bank of
The persons named in the attached Schedule are pensioners or claimants for pensions under the above-named Act, and I have to request you will be so good as to show in the Schedule particulars of any money or securities held by you on account of such persons. I may inform you that in section 28 sub-section (2) of the Act, it is provided as follows:—
“The Registrar may require any person whom he believes to be in a position to do so, to furnish to him, for submission to the Magistrate, a confidential report as to the circumstances or the financial transactions of any claimant or pensioner or of any relatives of a claimant or pensioner; and any person who, on being required to do so by the Registrar, fails to furnish a report within a reasonable time, or furnishes a report containing any statement which is untrue in any particular, shall be guilty of an offence.” Penalty: One hundred pounds or six months’ imprisonment.
I certify, after due inquiry, that to the best of my knowledge and belief, the particulars of money or securities shown in the Schedule above are correct.
Manager.
Date
Form 9.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
SEARCH FOR PARTICULARS AS TO AGE OR ARRIVAL IN AUSTRALIA.
From the Registrar of Pensions at
To the Deputy Commissioner of Pensions at
* Please cause the date of arrival in Australia to be verified in the following case.
* Please cause search to be made in order to ascertain the age of the claimant, who has given the following information with regard to his (or her) children.
Registrar of Pensions at Date
Present Name of Claimant (in fall)
Name on ship’s books
Immigrant†Passenger†Member of Crew†
Name of ship from the port of to the port of Date of arrival at latter port
Full Names.
Dates of Birth.
Places of Birth.‡ (Name of State required as well as Name of Place.)
Claimant’s Age then given.
Wife’s (or Husband’s) Age then given.
Registered by
Birthplace of (H) Husband, or (W) Wife.
From the Deputy Commissioner to the Registrar—
Date of arrival
† has been verified, and age appearing in shipping record was at the following date, viz:—† cannot be traced.
Details as to ages have been supplied above.
Deputy Commissioner.
Date
* If claimant is able to produce satisfactory evidence as to age, the second request should be struck out. If claimant is able to produce satisfactory evidence as to arrival in Australia, the first request should be struck out.
† Strike out what is incorrect.
‡ State also places of registration if not registered at places where born.
Form 10.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908—1926.
To the Officer in Charge of Police at
Claimant—Name
Occupation
Address
It is requested that you will be good enough to make all such inquiries as may be necessary for a full investigation of a claim for an Old-age*/Invalid* Pension made by the above-named, and to forward to me a report on this form with as little delay as may be. The inquiries should be made as far as possible from persons other than the claimant or the claimant’s relatives.
The report may be returned to me without prepayment of postage if enclosed in the official envelope of any Commonwealth or State Department and indorsed “Pensions.”
Registrar of Pensions.
Date Place
Questions on this page only to be answered in case claimant is applying for Invalid Pension.
Questions.
Answers.
What is the claimant’s state of health; or what, in general terms, is the nature of the invalidity or accident?
Does it incapacitate claimant for any work?
Have you any reason to believe that it was self-induced, or in any way brought about with a view to obtaining pension?(if so, state your reason.)
Is claimant confined to bed or to the house, or is he able to leave the house?
Did claimant’s incapacity become permanent in Australia?
What was claimant’s last occupation?.......
How long ago was this?
Has claimant any claim against any employer, company, or other person or body, compellable under private contract or public enactment to adequately maintain or compensate claimant on account of accident or invalid state of health?(Give particulars.)
Do you believe that claimant is adequately maintained by his relatives?(State your reasons.)
In your opinion, what is claimant’s age?
What documentary evidence (if any) as to age have you seen?(Evidence should be produced, if possible.)
Has claimant lived continuously in Australia for {†20 years or more/5 years or more} and is claimant now residing in Australia?(Continuous residence is not deemed to have been interrupted by occasional absences, not exceeding in the aggregate one-tenth of total period of residence, and a claimant is not deemed to have been absent during any period of absence if during that period his home was in Australia; and, if married, if his wife and family resided there and were maintained by him.)
What documentary evidence (if any) as to length of residence have you seen?(Evidence should be produced if possible.)
Is the claimant a natural-born British subject?
* Strike out what is inapplicable.
† 20 years is the qualification necessary for an Old-age Pension claimant: 5 years for an Invalid Pension claimant. Strike out which is inapplicable.
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td colspan="2" style="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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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:top"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If the claimant is not a natural-born British subject, when and where was claimant naturalized?</span></p></td><td colspan="2" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Were naturalization papers produced to you?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If not produced, claimant should give reason).</span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is claimant an Asiatic, born outside of Australia, or an aboriginal native of Australia, Africa, the Islands of the Pacific, or New Zealand?</span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is claimant of good character?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If not, give particulars.)</span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Ought a warrant to be granted for payment of pension (if allowed) through a nominee owing to claimant’s health, habits, &c.?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:17"><img src="image.006.png" width="8" height="254" alt="Brace grouping questions that need not be answered in respect of claimants for invalid pensions" style="margin-top:22.33pt; margin-left:5.48pt; position:absolute"></span><span style="font-family:'Times New Roman', serif">(State which, also give name and address of suitable warrantee, if required).</span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td rowspan="2" style="width:6.36%; height:1pt; margin-left:auto; writing-mode:tb-rl; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:1pt; margin-left:auto; writing-mode:tb-rl; overflow:hidden"><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">These questions need not be answered in respect of claimants for Invalid Pensions.</span></p></div></td><td style="width:45.44%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-left:21.6pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If claimant is a husband, has he for twelve months or upwards during five years immediately preceding the date of the claim, without just cause, deserted his wife, or without just cause failed to provide her with adequate means of maintenance, or neglected to maintain any of his children being under the age of fourteen years?</span></p><p style="margin-left:43.2pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If you have any knowledge of a maintenance order, please say so.)</span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:45.44%; 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:21.6pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If claimant is a wife, has she for twelve months during five years immediately preceding the date of the claim, without just cause, deserted her husband, or deserted any of her children being under the age of fourteen years?</span></p></td><td colspan="2" style="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; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="border-bottom:0.75pt solid #000000; vertical-align:top"></td></tr><tr style="height:18.15pt"><td colspan="2" rowspan="3" style="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; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:39.75pt"><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; font-size:10pt"><span style="font-family:'Times New Roman', serif">In case of married claimant, answers to questions on this page should relate to property and income of both husband and wife.</span></p></td></tr><tr style="height:17.25pt"><td style="width:23.72%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Husband.</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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Wife.</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the value of the claimant’s property and where situated?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Reply to this question should give particulars of houses, land, money in hand, money in bank, money lent, furniture, live stock, harness, &c. The nature and value of each class of property should be shown.)</span></p></td><td style="width:23.72%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><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; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If claimant has money in the Savings Bank, official number of book and name of branch to be quoted. Also state if bank book produced.)</span></p></td><td style="width:23.72%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What encumbrances (such as mortgages, &c.) exist on the property?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If any, give full name and address of mortgagee, and also amount concerned.)</span></p></td><td style="width:23.72%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:0pt"><td style="width:28.95pt"></td><td style="width:207.05pt"></td><td style="width:108.05pt"></td><td style="width:110.65pt"></td><td style="width:0.75pt"></td></tr></tbody></table>
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:17.25pt"><td colspan="2" rowspan="3" style="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; font-size:9pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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; font-size:9pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:44.25pt"><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; font-size:9pt"><span style="font-family:'Times New Roman', serif">In case of married claimant, answers to questions on this page should relate to property and income of both husband and wife.</span></p></td></tr><tr style="height:1pt"><td style="width:24.9%; 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; font-size:9pt"><span style="font-family:'Times New Roman', serif">Husband.</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; font-size:9pt"><span style="font-family:'Times New Roman', serif">Wife.</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Does the property include a home in which the claimant permanently resides?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(If claimant has more than one house indicate that which is the home, and state its value and encumbrance.)</span></p></td><td style="width:24.9%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><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; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">What amount per week does the claimant earn on an average, and in what occupation; and does remuneration include board or lodging in addition to money wages?</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Does the claimant receive free board or lodging?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(If so, give particulars.)</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Has claimant ceased work </span><span style="font-family:'Times New Roman', serif; font-style:italic">permanently?</span><span style="font-family:'Times New Roman', serif"> If not, what are claimant’s prospects of further employment?</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">How has claimant been maintained during the last twelve months?</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">What amount of other income or means of support has the claimant?</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Has the claimant directly or indirectly deprived himself or herself of property or income in order to qualify for or obtain a pension?</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="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:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">What property has claimant parted with during recent years?</span></p></td><td style="width:24.9%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="2" style="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; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:50.5%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td><td style="border-top:0.75pt solid #000000; vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Has claimant at any time applied for a Commonwealth or State pension? If so, when and where?</span></p></td><td colspan="3" style="border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Would pension be probably misspent in drink or otherwise?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(Give particulars, if necessary.)</span></p></td><td colspan="3" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Are husband and wife living together?</span></p><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">If not, are they living apart pursuant to any decree, judgment, order, or deed of separation?</span></p></td><td colspan="3" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">If claimant is a husband, has his wife applied for or been granted a pension, or will she soon apply?</span></p></td><td colspan="3" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">If claimant is a wife, has her husband applied for or been granted a pension, or will be soon apply?</span></p></td><td colspan="3" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Do you know any reason why pension should not be granted?</span></p></td><td colspan="3" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">At what Post office should pension, if granted, be paid?</span></p></td><td colspan="3" style="border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td style="width:50.5%; 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:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">What are the names and addresses of the persons from whom you have obtained the information contained in this report?</span></p></td><td colspan="3" style="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; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:0pt"><td style="width:230pt"></td><td style="width:0.65pt"></td><td style="width:113.4pt"></td><td style="width:107.75pt"></td><td style="width:3.65pt"></td></tr></tbody></table>
I have made inquiries in the matter of this claim, and, to the best of my knowledge and belief, the information given in this document is correct.
Signed
(Insert here name and rank of Member of Police Force who has made inquiries.)
Date
From the Officer in Charge of Police at
To the Registrar of Pensions at
Above report is forwarded for your information.
Officer in Charge of Police.
Date
Form 11.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
NOTICE TO ATTEND INVESTIGATION.
* Alter this word if investigation is to be made at a place other than a Courthouse.
To
Address
Take notice that the investigation of your pension claim will be made on day, the day of 19 , at the Courthouse* at at o’clock in the noon, and that you are then and there required to attend and to support your claim by the production of papers or other evidence.
Dated at this day of 19
Registrar of Pensions.
Form 12.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
Sir,
I have the honour to inform you that*
have made claims for pensions, and that they have been requested† to appear before you at the Court-house,‡ at on
at o’clock in the noon.
Registrar.
To Esq.,
Magistrate.
* Names of Claimants.
† If not requested to attend, alter wording to agree with the facts.
‡ Alter this word if investigation is to be made at a place other than a Court-house.
Form 13.
To the Magistrate at
The attached claim is forwarded to you, together with the following reports and documents:—
* The claimant is unable to attend by reason of
Registrar of Pensions at Date
* Strike out if not required.
Form 14.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
Office of Registrar of Pensions.
(Date)
Memo. to
In reference to your claim for a pension, you are requested to attend at for medical examination by between the hours of a.m. and a. m on p. m. p. m the taking this notice with you. The fee for this examination will be paid by the Commonwealth.
You must attend at the appointed time or notify me at once of your inability to do so.
Registrar of Pensions.
Form 15.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
Office of Registrar of Pensions.
(Date)
Memo. to Dr.
(Commonwealth Medical Referee),
Name and Address of Claimant
The above-named has made a claim for an Invalid Pension, and
*
(has been requested to call on you for examination between the hours ofa. m. and a.m. onp. m. p.m.
*
you are requested to visit claimant at the address set out and there make the necessary examination.
Kindly forward direct to this office the result of your examination in accordance with Form 16.
In rendering your account half-yearly to the Deputy Commissioner you are requested to attach this notice thereto. The fee chargeable in the ease of a claimant attending your consulting rooms is 10s., and in the case of your visiting claimant, 15s.
Registrar of Pensions.
* The Registrar to strike out what is inapplicable.
Form 16.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
MEDICAL CERTIFICATE FOR INVALID AND OLD-AGE PENSION PURPOSES.
(a) Fully describe claimant’s general condition.
(b) “Invalidity” or “Accident.”
(c) Name definite disease or accident.*
(d) Fill in period of time. If self-induced strike out the word “not.”
(e) “Invalidity” or “Accident.”
(†) Strike out what is inapplicable.
I,
hereby declare that I have this day examined
of a claimant for
a pension under the above-named Act.
I find that the claimant—
(1) Is about years of age.
(2) Is suffering from (a)
(3) The above (b) is the result of (c)
(4) It has in my opinion existed for (d) and has not been self-induced.
(5) The (e) †is such / is not such as to render claimant “permanently incapacitated for work, or blind.”
I therefore certify that, after full and careful examination, I am of opinion that claimant† is / is not permanently incapacitated for work or blind, and† is / is not in that respect entitled to a pension under the Invalid and Old-agePensions Act 1908-1926.
Commonwealth Medical Referee.
(Address)
Date 19
* Attention is directed to the specific requirements of the Act in all cases coming within its provisions namely, that the accident or invalid state of health must be:—
(1) Permanent, and (2) Such as to incapacitate the claimant for work.
Note.—Cases of a transient nature, only temporarily incapacitating the claimant for work; or of a permanent nature, but only partially incapacitating him for work, do not come within the Act.
To The
Registrar of Pensions.
Form 17.
RECOMMENDATION OF MAGISTRATE.
Hereunder I specify all the material points which I find to be respectively proved, disproved, and unproved or insufficiently proved:—
Brace grouping Proved, Disproved, and Unproved or Insufficiently ProvedClaimant is a—
(1) *Male who has attained the age of 65 years.......(2) *Male who is permanently incapacitated for work and has attained the age of 60 years(3) *Female who has attained the age of 60 years.....
*
Proved (by )Disproved.Unproved or Insufficiently Proved.
Length of residence sufficient..................
*
Proved.Disproved.Unproved or Insufficiently Proved.
Good character............................
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant is not disqualified by desertion of husband, wife, or children, or by neglect to maintain wife or children
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant’s income and property are not sufficient in amounts to preclude the grant of a pension—the annual income being £ and the net capital value of accumulated property being £
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant has not directly or indirectly deprived himself of property or income in order to qualify for or obtain a pension
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant has not within six months been refused a pension certificate under the Act except for reasons set out in section 17(g)
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant is a natural born or naturalized subject of the King, and claimant is not an Asiatic (except one born in Australia or an Indian born in British India), or an aboriginal native of Australia, Africa, the Islands of the Pacific, or New Zealand
*
Proved.Disproved.Unproved or Insufficiently Proved.
* I recommend the rejection of the claim.
* I am satisfied that the claimant is deserving of a pension, and I recommend that a pension of £ per annum be granted.
* It appears to me that the claimant, although otherwise qualified for, is unfit to be intrusted with, a pension, and I recommend that the claimant be sent to a benevolent asylum or charitable institution.
Magistrate at Date
* Strike out what is inapplicable.
Form 18.
RECOMMENDATION OF MAGISTRATE.
Hereunder I specify all the material points which I find to be respectively proved, disproved, and unproved or insufficiently proved:—
Age of more than 16 years and permanent incapacity for work or permanent blindness
*
Proved.Disproved.Unproved or Insufficiently Proved.
Length of residence sufficient..................
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant has whilst in Australia become permanently incapacitated or blind
*
Proved.Disproved.Unproved or Insufficiently Proved.
The accident or invalid state of health was not self-induced, nor in any way brought about with a view to obtaining a pension.
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant has no claim against any employer, company, or other person or body compellable to adequately maintain or compensate him on account of accident or invalid state of health
*
Proved.Disproved.Unproved or Insufficiently Proved
Claimant’s income and property are not sufficient in amounts to preclude the grant of a pension—the annual income being £ and the net capital value of accumulated property being £………..
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant’s relatives, namely, father, mother, husband, or wife, do not adequately maintain him
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant has not directly or indirectly deprived himself of income or property in order to qualify for a pension
*
Proved.Disproved.Unproved or Insufficiently Proved.
Claimant is a natural born or naturalized subject of the King, and claimant is not an Asiatic (except one born in Australia or an Indian born in British India), or an aboriginal native of Australia, Africa, the Islands of the Pacific, or New Zealand
*
Proved.Disproved.Unproved or Insufficiently Proved.
* I recommend the rejection of the claim.
* I am satisfied that the claimant is deserving of a pension, and I recommend that a pension of £ per annum be granted.
* It appears to me that the claimant, although otherwise qualified for, is unfit to be entrusted with, a pension, and I recommend that the claimant be sent to a benevolent asylum or charitable institution.
Magistrate at Date
* Strike out what is inapplicable.
Form 19.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
NOTICE OF INTENTION TO ADDUCE FRESH EVIDENCE.
From*
To the Registrar of Pensions at
I hereby give notice that on the day of 19 I intend to adduce before the Magistrate at fresh evidence in respect of matters found by the Magistrate on the day of 19 to be unproved or insufficiently proved. The fresh evidence will be†
Signature of Claimant
Date
* State full name, address, and occupation of claimant.
† Set out the nature of the evidence to be adduced.
Form 20.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
APPEAL TO MINISTER.
To the Treasurer of the Commonwealth of Australia.
I,*
do hereby appeal to the Minister against the recommendation of the Magistrate at with regard to† and in connexion therewith submit the following‡
Signature of Claimant
Date
* State name, occupation, and address.
† State matters appealed against.
‡ State facts in support of appeal.
Form 21.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
NOTICE OF THE GRANT OF PENSION
To
I have to acquaint you that your claim for a pension has been allowed, and a pension certificate will be issued to you on application to the Postmaster at You are entitled to payment in advance as from at the rate of per fortnight. The total amount already due to you, including the fortnightly instalment due on , is £
Deputy Commissioner of Pensions.
Place
Date 19
Special attention is invited to the notice on the back hereof.
[Back of Form]
NOTICE TO PENSIONERS.
The amount of a pension is liable to be affected by changes in the income or property of a pensioner or his wife (or husband)—see sections 24 and 26 of the Invalid and Old-age Pensions Act 1908-1926.
In order to avoid danger of overpayment and consequent necessity for a refund by the pensioner, pensioners should notify the Deputy Commissioner of Pensions of any change in their financial circumstances (including those of pensioner’s wife or husband).
The following are examples of cases which should be brought under notice: Increase in income, increase in banking account, change of address when pensioner has been living in a home owned by himself or his wife (or husband), receipt of money from sale of houses or land, legacy, insurance, or other source.
Form 22.
————
Form 22.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
NOTICE OF REJECTION OF CLAIM.
To
I have to acquaint you that your claim for a pension has been rejected on the ground that
Deputy Commissioner of Pensions.
Place
Date 19
Form 23.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
INCOME AND PROPERTY STATEMENT.
The pensioner must answer fully and correctly the questions contained herein, and make the declaration before one of the persons mentioned. The form, when completed, should be returned immediately to the Deputy Commissioner of Pensions. An envelope addressed to the Deputy Commissioner will be handed to the pensioner by the Postmaster.
Should the form not be returned within four weeks, payment of pension will be stopped.
Clause 5 (2.) of the Invalid and Old-age Pensions Regulations reads:—
If any person wilfully makes any false statement in any declaration provided for under these Regulations he shall, if subject to no higher penalty under the Act, be liable to a penalty not exceeding One hundred pounds.
Note.—Where the pensioner is married, information is required concerning both husband and wife.
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:14.55pt"><td rowspan="2" style="width:49.84%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:44.7pt"><td style="width:24.5%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning the Pensioner.</span></p></td><td style="width:25.66%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Information concerning the Pensioner’s Wife or Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is your full name?</span><span style="width:119.36pt; font-family:'Lucida Console', monospace; display:inline-block">...................</span></p></td><td style="width:24.5%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">At what post office is your pension paid?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is your pension certificate number?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is your fortnightly rate of pension?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Are you single, married, widower, widow, or divorcee.?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State which.)</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If married, is your husband or wife a pensioner?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Are you at present in employment?</span><span style="width:75.21pt; font-family:'Lucida Console', monospace; display:inline-block">............</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state name and address of employer, and rate of wages.)</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">By whom were you employed during the last twelve months?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State names and addresses of employers.)</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How much did you earn during the last twelve months?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">During the last twelve months did you receive free board or free lodging, or both?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State which, for how long, and from whom received.)</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Do you keep a shop, 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:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If so, state nature of same; also state gross receipts and profit made during the last twelve months?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><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:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Reply should include rents, dividends, interest, or any other similar income, but not income in the form of donations from children or Commonwealth War Pensions.)</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What house or land property do you own?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Give situation of each house, and its value.)</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If you own only one house, do you live in it?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:3pt; margin-left:7.2pt; margin-bottom:3pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">If you own more than one house, which do you live in?</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:3pt; margin-bottom:3pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is any of your property mortgaged or subject to any other debt?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state clearly which property is mortgaged; also the name and address of the person to whom the money is owing, and the amount of the mortgage.</span></p></td><td style="width:24.5%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.66%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><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:49.84%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:1pt"><td style="width:24.02%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Information concerning the Pensioner.</span></p></td><td style="width:26.14%; 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-top:6pt; margin-bottom:6pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Information concerning the Pensioner’s Wife or Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Have you a share or interest in any property other than that above mentioned?</span></p><p style="margin-left:21.6pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(If so, give particulars.)</span></p></td><td style="width:24.02%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Do you own any horses, cattle, sheep, or other live stock?</span></p><p style="margin-left:21.6pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(Give particulars and value.)</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Do you own any vehicles, implements, &c.</span></p><p style="margin-left:21.6pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(Give particulars and value.)</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Is your life assured?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(If so, state name of company, number and amount of policy, and when payable.)</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Have you any money in any bank, savings bank, building society, or other institution, or any cash in hand?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(Give details as to amounts, name and address of bank, &c.)</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Have you disposed of any property by sale or deed of gift since the pension was granted?</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(Give full particulars.)</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Does any person owe you money?</span><span style="width:81.98pt; font-family:'Lucida Console', monospace; display:inline-block">...............</span></p><p style="margin-left:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(If so, give particulars.)</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:-7.2pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Have you any property or money otherwise invested not previously disclosed in this statement?</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td style="width:49.84%; 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; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">What is your present postal address?</span><span style="width:73.99pt; font-family:'Lucida Console', monospace; display:inline-block">.............</span></p></td><td style="width:24.02%; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.14%; 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; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr></tbody></table>
Important.—All questions must be answered in words. Strokes will not be accepted.
——
DECLARATION.
I*
of†
do hereby declare that I am the pensioner whose income and property are set out in the foregoing statement, and that the contents of such statement are true and correct in every particular.
Declared atthe day of 19
(Signature of Pensioner.)
Before me‡
* Full name of pensioner.
† Address and occupation.
‡ Person before whom declaration is made to add title, such as “Postmaster,” &c.
Note.—The declaration may be made before any of the following persons:—A postmaster or postmistress or person in charge of a post office, 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 1908-1926, a minister of religon, 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.
Form 24.
COMMONWEALTH OF AUSTRALIA.
———
The Invalid and Old-age Pensions Act 1908-1926.
The Postmaster,
Under separate cover I am forwarding a supply of Income and Property Statements in respect of certain pensioners paid at your office—also a number of envelopes addressed “Deputy Commissioner of Pensions .”
On the occasion of the next payment, you will please hand a statement to each pensioner, together with an addressed envelope, and at the same time request the pensioner to fill in and return the document to the Deputy Commissioner of Pensions without delay.
Deputy Commissioner of Pensions.
Place
Date
COMMONWEALTH OF AUSTRALIA.
Form 25.
The Invalid and Old-age Pensions Act 1908-1926.
The Officer in Charge of Police, Date
Hereunder are the names of some pensioners in your district, together with particulars of the income and property which, according to departmental papers, are possessed by the pensioners and their wives or husbands. I shall be glad if you will kindly indicate whether the police are aware of any income or property not mentioned in this list. It is not expected that the police should visit every pensioner’s home. What is desired is information which may already be in possession of the police as to any cases in which it would seem that the Department has been given incorrect information.
I certify that a pension, as detailed on the other side hereof, has been granted. The first fortnight’s instalment of the pension was due on 19 for the fortnight commenced on that date.
Deputy Commissioner.
The pension is payable only at the office named herein, and no application for temporary transfer to another office will be entertained.
The following instructions must be strictly adhered to:—A person authorized by warrant in Form 34 to receive payment for the benefit of a pensioner must not draw instalments of the pension after the pensioner’s decease, or during the time that pensioner is absent from Australia, or is an inmate of any benevolent asylum, hospital, or asylum for the insane.
This certificate must be produced when application is made for payment of each instalment of pension, and no instalment will be paid without its production. Any instalment not applied for within 21 days after its due date may be forfeited.
Transfers to another office of payment should be noted hereunder:—
Payment to be made in future at—
Signature of Postmaster.
Date.
Pension Certificate Number Pensioner’s Name
Fortnightly Rate shillings pence, payable at
Pensioner’s Signature(or witnessed mark)
Witness to Mark
The Invalid and Old-age Pensions Act 1908-1926 includes the following provision:—
“Every pension shall be deemed to be granted and shall be held subject to all the provisions of this Act, and to the provisions of any other Act amending or repealing or in substitution for this Act which may at any time be passed, and no pensioner shall have any claim for compensation or otherwise by reason of his pension being affected by the operation of this Act or any such other Act.”
The officer paying to place his date stamp on the proper space when payment is made. If he has no date stamp, he must place his initials and the date in the space (in ink, not pencil). When, for example, the instalment due on , is paid, the date stamp must be placed in the space in which the date , is printed.
Form 27.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
APPLICATION FOR DUPLICATE PENSION CERTIFICATE.
To the Deputy Commissioner of Pensions at
1,
of
being a pensioner under the aforesaid Act, hereby make application for a duplicate Pension Certificate in lieu of the original Certificate No payment in accordance with which is made at ; and in support of the application I hereby declare as follows:—
1. The name or names of the pensioner or pensioners is or are
The original Certificate was duly issued to me and has been *lost. / *destroyed.
3. †
4.* I have made diligent search for the lost Certificate, but have been unable to find it.
5. The last instalment of the pension paid to me was that due on
6. I do hereby solemnly declare that this statement is true.
Declared by the said atthis day of 19before me—‡ §
Applicant.
* Strike out what is inapplicable.
† If destroyed, state when and how.
‡ The person before whom this declaration is made to sign here and add the title by which he takes 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 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 1908-1926, 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.
Form 28.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
APPLICATION FOR CHANGE OF PLACE OF PAYMENT.
(Application, accompanied by pension certificate, must be sent to Postmaster or other officer who pays pension.)
Address
Date
Pension Certificate No.
I hereby apply that place of payment of my pension be changed from to for the following reasons:—
My new address will be:
Signature of Applicant
I beg to report to the Deputy Commissioner of Pensions at that I have authorized the transfer from to , and the Identification Card, duly endorsed, has been forwarded to the Postmaster. The last payment made at this office was due on “Pension Thursday,” the 19 at the rate of p. f.
Postmaster or Paying Officer.
Rate of pension to be shown in all cases.
N.B.—Postmasters cannot authorize transfers to places outside the Commonwealth.
Pension Certificate No. Form 29.
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:359.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:72pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">COMMONWEALTH OF AUSTRALIA.</span></p><p style="margin-left:72pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">——</span></p></td><td style="width:81.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Post Office Date Stamp to be</span></p></td></tr><tr><td style="width:359.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:72pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">The </span><span style="font-family:'Times New Roman', serif; font-style:italic">Invalid and Old-age Pensions Act </span><span style="font-family:'Times New Roman', serif">1908-1926.</span></p></td><td rowspan="3" style="width:81.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:6"><img src="image.022.png" width="40" height="48" alt="Box to be stamped" style="margin-top:1.88pt; margin-left:26.17pt; position:absolute"></span><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr><td style="width:359.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:72pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">——</span></p></td></tr><tr><td style="width:359.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:72pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">RECEIPT FOR INSTALMENT OF PENSION.</span></p></td></tr><tr><td style="width:359.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:72pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:81.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">placed in this square.</span></p></td></tr></tbody></table>
I acknowledge to have received the sum of £ : : being fortnightly pension instalment due on in accordance with Pension Certificate numbered as above.
Signature
Note.—Whenever payment of a pension instalment is made, the paying officer will hand to the pensioner a blank form of receipt, which must be brought back on the next pension pay-day, already filled in and signed. The pensioner must not hand the receipt to another person under any circumstances but must bring it back himself (or herself).
The attention of pensioners is drawn to notice on back.
[Back of Form.]
NOTICE TO PENSIONERS.
The amount of a pension is liable to be affected by changes in the income or property of a pensioner or his wife (or husband)—see sections 24 and 25 of the Invalid and Old-age Pensions Act 1908-1926.
In order to avoid danger of overpayment and consequent necessity for a refund by the pensioner, pensioners should notify the Deputy Commissioner of Pensions of any change in their financial circumstances (including those of pensioner’s wife—or husband).
The following are examples of cases which should be brought under notice:—Increase in income, increase in banking account, change of address when pensioner has been living in a home owned by himself or his wife (or husband), receipt of money from sale of houses or land, legacy, insurance, or other source.
Pension Certificate No.
Form 30.
Post Office Date Stamp to be
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
placed in this square.
RECEIPT FOR INSTALMENT OF PENSION.
I acknowledge to have received, for the benefit of the pensioner, the sum of £ : :, being fortnightly pension instalment due on in accordance with Pension Certificate numbered as above. I have good reason to believe that the pensioner is alive in Australia, and that the pensioner is not an inmate of any benevolent asylum, hospital, or asylum for the insane. I last saw the pensioner on
Signature
Note.—Whenever payment of a pension instalment is made, the paying officer will hand to the warrantee a blank form of receipt, which must be brought back on the next pension pay-day, already filled in and signed. The warrantee must not hand the receipt to another person under any circumstances, but must bring it back himself (or herself).
The attention of warrantees is drawn to notice on back.
[Back of Form.]
NOTICE.
The amount of a pension is liable to be affected by changes in the income or property of a pensioner or his wife (or husband)—see sections 24 and 25 of the Invalid and Old-age Pensions Act 1908-1926.
In order to avoid danger of overpayment and consequent necessity for a refund by the pensioner, pensioners should notify the Deputy Commissioner of Pensions of any change in their financial circumstances (including those of pensioner’s wife—or husband).
The following are examples of cases which should be brought under notice:—Increase in income, increase in banking account, change of address when pensioner has been living in a home owned by himself or his wife (or husband), receipt of money from sale of houses or land, legacy, insurance, or other source.
Form 31.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
APPLICATION FOR PAYMENT OF FORFEITED INSTALMENT.
Full Name of Pensioner
Full Address
Full Name of other person (if any) authorized to receive payment
Full Address
Pension payable at Certificate No.
To the Registrar of Pensions
at
I being the pensioner or (as the case may be) the person authorized to draw the above-named pension, apply for payment of the forfeited instalment (or instalments) due for the period of fortnights ended 19 , amounting to £
I declare that the particulars given in reply to the following questions are true and correct:—
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td style="width:56.78%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:57.6pt; margin-bottom:0pt; text-indent:-28.8pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">a</span><span style="font-family:'Times New Roman', serif">) Has pensioner during any portion of the period referred to been an inmate of a benevolent asylum, hospital, or asylum for the insane?</span></p></td><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">a</span><span style="font-family:'Times New Roman', serif">) †</span></p></td></tr><tr style="height:1pt"><td style="width:56.78%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:57.6pt; margin-bottom:0pt; text-indent:-28.8pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">b</span><span style="font-family:'Times New Roman', serif">) Why was the amount not applied for in due time?</span></p><p style="margin-left:64.8pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(Give full particulars.)</span></p></td><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">(</span><span style="font-family:'Times New Roman', serif; font-style:italic">b</span><span style="font-family:'Times New Roman', serif">)</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="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="height:0pt; text-align:left; display:block; position:relative; z-index:5"><img src="image.024.png" width="11" height="48" alt="Brace grouping details of declaration and signature of applicant" style="margin-top:0.98pt; margin-left:284.87pt; position:absolute"></span><span style="font-family:'Times New Roman', serif">Declared at</span><span style="width:7.22pt; text-indent:0pt; display:inline-block"> </span><span style="width:36pt; text-indent:0pt; display:inline-block"></span><span style="width:36pt; text-indent:0pt; display:inline-block"></span><span style="width:36pt; text-indent:0pt; display:inline-block"></span><span style="font-family:'Times New Roman', serif">this</span></p></td><td rowspan="3" style="width:33.36%; padding-right:2pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">Applicant.</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:28.8pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">day of</span><span style="width:15.4pt; display:inline-block"> </span><span style="width:36pt; display:inline-block"></span><span style="width:36pt; display:inline-block"></span><span style="width:36pt; display:inline-block"></span><span style="width:36pt; display:inline-block"></span><span style="font-family:'Times New Roman', serif">19</span><span style="width:25pt; display:inline-block"> </span><span style="font-family:'Times New Roman', serif">, before</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:28.8pt; margin-bottom:0pt; line-height:normal"><span style="font-family:'Times New Roman', serif">me—</span><span style="width:18.76pt; display:inline-block"> </span><span style="width:36pt; display:inline-block"></span><span style="font-family:'Times New Roman', serif">§ ║</span></p></td></tr><tr style="height:0pt"><td style="width:258.6pt"></td><td style="width:44.9pt"></td><td style="width:151.95pt"></td></tr></tbody></table>
† If pensioner was an inmate, give name of institution and dates of admission and discharge.
§ 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 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 1908-1926, 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.
To the Deputy Commissioner of Pensions,
I have GRANTED waiver of forfeiture of instalments for the period of
I have REFUSED waiver of forfeiture of instalments for the period of
Registrar of Pensions.
Date .
[The Registrar’s attention is particularly directed to Section 40 of the Act and Regulation 29.]
Form 32.
COMMONWEALTH OF AUSTRALIA.
———
The Invalid and Old-age Pensions Act 1908-1926.
———
WAIVER OF FORFEITURE.
I hereby grant this warrant, waiving forfeiture of the instalment of the pension which was due to pursuant to Pension Certificate No. on the following payday, viz. but which became forfeited because it was not applied for within twenty-one days of the due date. The instalment may now be paid as though it had not been forfeited. This warrant must be presented to the Postmaster or other paying officer.
Dated at this day of 19
Registrar of Pensions.
Note for Postmaster.—This Warrant must be pinned to the receipt for the instalment concerned.
Form 33.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
APPLICATION FOR WARRANT AUTHORIZING PAYMENT TO PERSON OTHER THAN THE PENSIONER.
Note.—A Warrant cannot be issued in respect of any pensioner who is about to leave Australia or who is an inmate, or is about to become an inmate, of a benevolent asylum, hospital, or asylum for the insane.
To the Registrar of Pensions at
I, (a)
hereby apply for a warrant under the Act directing that until the warrant is cancelled all instalments of the pension payable to me at pursuant to Pension Certificate No. may be paid to (b) for my benefit, on the grounds (c)
I consent hereto. I am already the holder of warrants for payment of pensions in the following cases, and no others:—
I am *over/*under the age of 21 years.
Signature of Proposed Payee
I hereby certify that the pensioner and the proposed payee are personally known to me, and that owing to the pensioner is now unable, and, in my opinion, will be unable for a period of † to collect the pension instalments, and that the proposed payee is a suitable person for the purpose. ‡ §
To the Deputy Commissioner at
I am satisfied that this application should be granted.
Registrar of Pensions
at
Date
(a) Full name, occupation, and address of pensioner.
(b) Full name, occupation, and address of proposed payee.
(c) Set out briefly but clearly the grounds.
* Strike out the word which does not apply.
† State how long inability will probably continue.
‡ State title under which certificate is given.
§ This certificate must be signed by one of the following persons:—A postmaster or postmistress, or person in charge of a post office, 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 1908-1926, a minister of religion, an officer of the Commonwealth Department of the Treasury, a councillor of any municipallity or shire, or a member of the Parliament of the Commonwealth.
Form 34.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
WARRANT FOR PAYMENT TO PERSON OTHER THAN PENSIONER.
I direct that until* all instalments of the pension granted to (Certificate No. ) shall be paid to for the benefit of the pensioner
This Warrant, with the Pension Certificate, must be presented to the Postmaster or other paying officer whenever application is made for payment.
Deputy Commissioner of Pensions.
Date
Signature of person to whom Warrant granted
* If Warrant granted for an indefinite period, insert here “otherwise ordered by me.”
Form 35.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
PENSIONER IN CHARITABLE INSTITUTION.
I report that (Insert name of pensioner.) of (Insert address of pensioner.) who is a pensioner under the above-named Act, was admitted to the (Insert name of Institution.) on the day of 19 , and is still an inmate.
(Pension Certificate No. * Payable at ).
Signature
Office held by person reporting
Date
To the Postmaster or officer paying pensions at
Noted and forwarded to the Deputy Commissioner of Pensions.
The last payment made at this office was for the instalment due on
Signature
Postmaster at
Date
* The number should be filled in if the Pension Certificate has come under the notice of the person reporting.
Form 36.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
DISCHARGE OF PENSIONER FROM CHARITABLE INSTITUTION.
I certify that (Insert name and address of Pensioner.) who was admitted to the (Insert name of Institution.) on was discharged therefrom on the day of 19
Signature
Office held by person reporting
Date
To the Postmaster or officer paying pensions at
Note for Postmaster.—This Notice must be pinned to the receipt for the first instalment paid after the discharge.
For the purpose of calculating the amount payable to a pensioner on discharge, see “Instructions to Postmasters.”
Form 37.
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1926.
——
AMOUNT PAYABLE ON PENSIONER’S DISCHARGE FROM INSTITUTION.
Note.—In every case where a pensioner has been in a hospital or other charitable institution for more than 28 days, this form must be completed by the postmaster and attached to the receipt for the first payment made to the pensioner after discharge from the institution.
Name Fortnightly rate
Admitted to institution Discharged
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td style="width:75.52%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-21.6pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">The total period in institution (including day of admission but not including day of discharge) was</span><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:9.9%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-21.6pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:14.58%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">days.</span></p></td></tr><tr style="height:1pt"><td style="width:75.52%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-21.6pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Of that period pensioner is entitled to payment for</span><span style="width:84.45pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">............</span></p></td><td style="width:9.9%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-21.6pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">28</span></p></td><td style="width:14.58%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-right:7.2pt; margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">days.</span></p></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-21.6pt; text-align:justify; line-height:normal"><span style="font-family:'Times New Roman', serif">Period which cannot be paid for is</span><span style="width:154.09pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.......................</span></p></td><td style="width:14.58%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">days*.</span></p></td></tr></tbody></table>
The following instalments fell due while pensioner was in the institution, and have not been collected, namely:—
Amount
Instalment due on
19
£
Instalment due on
19
Instalment due on
19
Instalment due on
19
Instalment due on
19
Total..........................
£
* Deduct amount for period which cannot be paid for, namely:—
days, equal to fortnights and days
Amount payable £
Form 38.
COMMONWEALTH OF AUSTRALIA.
The Invalid and Old-age Pensions Act 1908-1926.
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:115.2pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">——</span></p></td><td style="width:104.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Consecutive Number.</span></p></td></tr><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-right:21.6pt; margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">ALTERATION OF</span><span style="font-family:'Times New Roman', serif; font-weight:bold"> </span><span style="font-family:'Times New Roman', serif">RATE OF PENSION.</span></p></td><td rowspan="3" style="width:104.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:1"><img src="image.026.png" width="117" height="45" alt="Box to be stamped" style="margin-top:0.88pt; margin-left:9.43pt; position:absolute"></span><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:115.2pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">——</span></p></td></tr><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-right:50.4pt; margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Advice to Postmaster.</span></p></td></tr></tbody></table>
Pensioner’s name
Pensioner’s address
Certificate No. Payable at
It has been decided to amend this pension from to per fortnight, commencing with the instalment due on
The Postmaster is hereby instructed to pay on and subsequent instalments at the amended rate until further notice.
The Pensioner has been requested to hand you the certificate for amendment. Please make the necessary correction and also note the alteration in your register of payments and on the identification card.
Date Deputy Commissioner of Pensions.
This advice to be retained by Postmaster for at least six months.
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:100.8pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">The </span><span style="font-family:'Times New Roman', serif; font-style:italic">Invalid and Old-age Pensions Act </span><span style="font-family:'Times New Roman', serif">1908-1926.</span></p></td><td style="width:104.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Consecutive Number.</span></p></td></tr><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:115.2pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">——</span></p></td><td rowspan="3" style="width:104.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:2"><img src="image.027.png" width="117" height="53" alt="Box to be stamped" style="margin-top:0.88pt; margin-left:9.43pt; position:absolute"></span><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:93.6pt; margin-bottom:3pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">POSTMASTER’S ACKNOWLEDGMENT.</span></p></td></tr><tr><td style="width:336.6pt; 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; font-style:italic">To the Deputy Commissioner of Pensions,</span></p></td></tr></tbody></table>
I have altered the register of payments, the identification card, and the pension certificate in accordance with the advice numbered as above.
Post Office Date Stamp.
Box to be stamped
Postmaster.
This acknowledgment, which should be completed by the Postmaster immediately after the above alterations have been made, should be detached and forwarded to the Deputy Commissioner.
Form 39.
COMMONWEALTH OF AUSTRALIA.
——
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:right; line-height:normal"><span style="font-family:'Times New Roman', serif">The </span><span style="font-family:'Times New Roman', serif; font-style:italic">Invalid and Old-age Pensions Act </span><span style="font-family:'Times New Roman', serif">1908-1926.</span></p></td><td style="width:104.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">Consecutive Number.</span></p></td></tr><tr style="height:17.1pt"><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:115.2pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">——</span></p></td><td rowspan="2" style="width:104.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:center; line-height:normal"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:0"><img src="image.028.png" width="111" height="41" alt="Box to be stamped" style="margin-top:2.47pt; margin-left:12.68pt; position:absolute"></span><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:17.55pt"><td style="width:336.6pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:115.2pt; margin-bottom:0pt; text-align:center; line-height:normal"><span style="font-family:'Times New Roman', serif">NOTICE OF ALTERATION.</span></p></td></tr></tbody></table>
To
Certificate No. Payable at
It has been decided to amend your pension from to per fortnight, commencing with the instalment due on
The Postmaster has been instructed to pay on and subsequent instalments at the amended rate until further notice.
In order to prevent any delay in payment, please hand your certificate as soon as possible to the Postmaster.
Reasons for alteration
If Invalid or Old-age pension is reduced, calculation should be shown.
Date Deputy Commissioner of Pensions.
Form 40.
COMMONWEALTH OF AUSTRALIA.
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The Invalid and Old-age Pensions Act 1908-1926.
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NOTICE OF DEATH.
† Insert full name and last address; also any other available particulars likely to assist in identification.
To the Deputy Commissioner of Pensions at
I advise that I have received notice of the death of† who died on the day of 19 aged years, and I believe *him/*her to have been a pensioner under the above-named Act whose pension was paid at
Registrar of Deaths.
Or Official charged with duty of registering Deaths.
Address of the Official making this report
* Strike out what is inapplicable.
Date 19
Regulations under the Invalid and Old-age Pensions Act 1908-1926 authorize the official registering a death to inquire, when registering the death of any person, whether the deceased was a pensioner under this Act, and, if so, to notify the Deputy Commissioner. As pensions are granted to persons of all ages from 16 years upwards, inquiry should be made in all cases.
Printed and Published for the Government of the Commonwealth of Australia by H. J. Green, Government Printer for the State of Victoria.