REGULATIONS UNDER THE INVALID AND OLD-AGE PENSIONS ACT 1908-1909.
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 1908-9 to come into operation forthwith. Such Regulations shall supersede the Provisional Regulations (Statutory Rules 1910, No. 121) under the said Act made on the 29th day of November, 1910.
Dated this 21st day of June, One thousand nine hundred and eleven.
DUDLEY,
Governor-General.
By His Excellency’s Command,
C. E. FRAZER,
for the Treasurer.
INVALID AND OLD-AGE PENSIONS REGULATIONS.
1. These Regulations may be cited as the Pensions Regulations.
2. The declaration to be made by the Commissioner, Assistant Commissioner, and Deputy Commissioners, under section 13 of the Act, shall be in accordance with Form 1.
3. Every 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 2a if claim is made for an Invalid Pension.
(2) A declaration, in accordance with Form 3, made by a person acquainted with the claimant.
(3) Identification card in accordance with Form 4.
4. All officers in 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.
5. (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 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 registrar, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
C.9525.—Price 1s.
(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.
6. Unless otherwise directed by the Commissioner, every Registrar shall keep a record, in accordance with Form 5, of pension claims received by him.
7. As soon as possible after the receipt of a claim the Registrar shall request the police to make a report in accordance with Form 6.
8. On receipt from the police of a report in accordance with Form 6, the Registrar shall examine the claim together with the police report, and other papers in the case. If it appears to him that on any material point the evidence 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. Provided that in any case in which it appears that no documentary evidence as to age is in the possession of the claimant, 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.
9. 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 10 and 11 respectively. Notice in accordance with Form 11 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 other sufficient cause, the claimant cannot reasonably be expected to attend, the notice in accordance with Form 10 need not be sent, and in that case a note shall be made on Form 12. 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.
10. If for any reason no Magistrate can 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.
11. The Registrar shall refer the claim to the Magistrate in accordance with Form 12.
11a. A claimant suffering from one of the following disabilities, or a disability of equal gravity, may be deemed to be permanently incapacitated for work:—
Accident.
The complete loss of a limb, where such loss renders the applicant permanently incapable of doing work.
The complete destruction of vision.
Invalidity.
Nervous System.
Locomotor ataxia (advanced). Cerebro-spinal sclerosis (advanced). Idiocy. Epilepsy-major, with frequent fits. Complete paralysis of a limb, where such paralysis renders the applicant permanently incapable of doing work. Advanced diabetes. Complete loss of vision at mature or advanced age.
Respiratory System.
Advanced tuberculosis, or miners’ complaint.
Circulatory System.
Organic disease of the heart, with failure of compensation. Thoracic aneurism.
Genito-urinary System.
Advanced kidney disease with dropsy.
Senility.
Advanced age (70 years and upwards) with marked degenerative changes.
Chronic articular rheumatism depriving sufferer of use of a limb, and rendering him permanently incapable of doing work.
Unspecified.
Cases of cancer and advanced wasting disease of any kind generally recognised as incurable and permanently unfitting the sufferer for manual or mental work.
11b. A medical certificate of permanent incapacity for work may be in accordance with Form 1a.
12. In calculating the maximum pension which may be recommended, there shall be deducted from fifty-two pounds the amount of claimant’s income, including income from accumulated property, and from the balance remaining, or from twenty-six pounds, whichever is lower in amount, there shall be deducted an amount, calculated as directed in section 24 sub-section 2 of the Act, in respect of the net capital value of the claimant’s accumulated property.
13. The Magistrate shall make his recommendation in accordance with Form 13 (indorsed on Form 2) if the claim is for an Old-age Pension, or on Form 13a (indorsed on Form 2a) 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.
14. (1) When a Magistrate has recommended the admission or rejection of a pension claim, he shall forward to the Registrar all the papers in the case together with the notes of evidence taken at the investigation of the case.
(2) Subject to paragraph (3) of this regulation, the Registrar shall send the papers and the evidence received from the Magistrate and the identification card to the Deputy Commissioner.
(3) In cases where the Magistrate’s recommendation for the rejection of the claim shows that no material point has been disproved, but 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 15 of intention to adduce fresh evidence, in which case the matter shall be dealt with as prescribed by section 32 of the Act. If no notice in accordance with Form 15 has 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.
15. A claimant may, within thirty days after the date of the Magistrate’s recommendation 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 16.
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16. 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 10 and 11, 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.
17. The determination of the Commissioner or Deputy Commissioner in relation to any claim shall be communicated to the claimant in accordance with Form 17 or 18.
18. The pension certificate in accordance with Form 19 and the identification card in accordance with Form 4 shall be forwarded to a postmaster or other officer, who shall retain the identification card, and deliver the certificate to the pensioner under departmental instructions.
19. 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 accounting, he 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.
19a. 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. Every such fortnight shall be known as a “pension fortnight,’’ and the first day of every ‘‘pension fortnight’’ shall be known as “Pension Thursday.”
19b. The due date of each instalment of pensions granted prior to the 1st December, 1910, shall be the first day following the pension fortnight for which the instalment is payable. In every such case, however, when a pensioner becomes an inmate of a Benevolent Asylum, Hospital, or Asylum for the Insane, moneys payable for all periods between the beginning of the “pension fortnight” in which he becomes an inmate and the end of the last pension fortnight completed before his discharge from the institution shall be deemed to be one instalment, and the due date thereof shall be the day of the pensioner’s discharge from the institution.
19c. The due date of each instalment of pensions granted on or after the 1st December, 1910, shall be the first day of the fortnight for which the instalment is payable. In every such case, however, when a pensioner becomes an inmate of a Benevolent Asylum, Hospital, or Asylum for the Insane, moneys payable for all periods between the end of the “pension fortnight’’ in which he becomes an inmate and the end of the ‘‘pension fortnight’’ in which he is discharged from the institution shall be deemed to be one instalment, and the due date thereof shall be the day of the pensioner’s discharge from the institution.
20. If a pensioner loses his pension certificate, he may make application, in accordance with Form 20, to the Deputy Commissioner for a duplicate certificate; and if the Deputy Commissioner issues a duplicate, he 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.
21. If a pensioner desires to permanently leave the place at which he resides to reside in another place, he may make application in Form 21 to the postmaster or other officer authorized to pay his pension, and if such 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 .” Also he shall make a note on the identification card as follows:—“The last payment made at this office was due on ‘Pension Thursday,’ the
191 .” To such notes he shall add his signature, and shall forward the identification card by post to the office to which payment is to be transferred. After the receipt of the identification card at that office, the postmaster or other officer there shall, subject to any instructions issued by the Commissioner or Deputy Commissioner, make payment of the pension as it falls due.
22. No pensioner shall be allowed to change the office of payment more than twice in any calendar year without the permission of the Deputy Commissioner.
23. The application in accordance with Form 21 shall, if approved by the postmaster or other officer, be transmitted to the Deputy Commissioner.
24. The receipt given by a pensioner shall be in accordance with Form 22. If the payee is other than the pensioner, the payee shall give a receipt in accordance with Form 23.
25. No payment shall be made to any person other than the pensioner unless such person is the holder of a warrant under sections 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, payments may be made to the holder of a warrant who has not seen the pensioner within the preceding three months.
26. In the event of any instalment being forfeited under section 40 of the Act, the pensioner, or other person the holder of a warrant, may make application, in accordance with Form 24, 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 25, 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.
27. Any undrawn instalment of a pension due at the date of a pensioner’s decease, if applied for within six months after such decease, may be paid to such person as in the opinion of the Deputy Commissioner has an equitable claim thereto.
28. With respect to warrants under sections 43 and 44 of the Act, authorizing payment of instalments of a pension to any benevolent or charitable society, minister of religion, justice of the peace, or other person, for the benefit of the pensioner, the following provisions shall apply:—
(1) The application for the warrant shall be in accordance with Form 26.
(2) The applicant may be the pensioner, the proposed payee, or any other reputable person competent to speak to the facts.
(3) The application shall bear the proposed payee’s consent in writing, and shall disclose the names of pensioners on whose behalf the proposed payee already holds warrants.
(4) The warrant shall be in accordance with Form 27, and shall continue in force until a date to be therein named or until otherwise ordered by the Deputy Commissioner.
(5) Where the Deputy Commissioner considers it expedient so to do, he may issue a warrant in accordance with Form 27, though application in accordance with Form 26 has not been made.
29. Whenever any instalment is payable under a warrant or waiver of forfeiture, the pension certificate shall be produced, at the time of payment, by the pensioner or other payee, together with the warrant or waiver.
30. When any pensioner enters any Benevolent Asylum, Hospital, or Asylum for the Insane, the Secretary or other officer of the Benevolent Asylum, Hospital, or Asylum for the Insane, should forthwith send a notification in accordance with Form 28 to the Postmaster or other officer authorized to pay the pension. Upon receipt of the notification the Postmaster or other officer shall suspend payment of the pension.
31. On receipt of notice of discharge, in accordance with Form 29, 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 institution for a period of less than four weeks, he shall be entitled to payment of his pension for the whole of such 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 to payment of his pension only from the twenty-eighth day preceding the date of his discharge. If a pensioner who has received payment for any “pension fortnight” becomes, during that fortnight, an inmate of a Benevolent Asylum, Hospital, or Asylum for the Insane, any consequent overpayment shall be adjusted by deduction from the first instalment payable after his discharge.
32. (1) Whenever the death of any person is reported to a Registrar of Deaths for registration, the Registrar may 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 should send to the Deputy Commissioner a notice of the death in accordance with Form 30.
(2) In this Regulation Registrar of Deaths means any Commonwealth or State officer charged with the duty of registering deaths.
33. Every Registrar, postmaster, and other officer charged with duties under the Act or Regulations, shall requisition for all the forms under these regulations which are required in connexion with his duties. Such requisition, in accordance with Form 31 or in ordinary letter-form, shall be made early enough in every case to secure a new supply of forms before the old stock becomes exhausted. The forms kept by Registrars shall include those required for the use of Magistrates. If from any cause printed forms are not in the hands of any Registrar, postmaster, or other officer, when required, the forms may be prepared wholly in manuscript.
34. As regards postage and telegrams, the following arrangements, made with the Postmaster-General’s Department, shall be observed:—
(1) Letters, &c., addressed to Registrars in connexion with Old-age Pensions, are to be transmitted without prepayment, if inclosed in the official envelopes of any Commonwealth or State Department, and indorsed “Old-age Pensions,” the postage thereon at prepaid rates to be paid by the Commissioner.
(2) The Letter-carrier delivering the correspondence will be supplied by the Postmaster with a docket showing the amount of postage due, such docket to be signed by the Registrar to whom the matter is addressed, or by his representative. Dockets will be supplied to Postmasters by the Treasury in book form, with counterfoils, and numbered consecutively.
(3) Letters, &c., sent by Registrars, except those addressed to other Registrars, which are covered by the arrangement set out in paragraph (1), and except those addressed to a Deputy Commissioner of Pensions, who will give a docket on delivery, are to be handed in at Post Offices, with dockets, to be supplied by the Registrars.
(4) Telegrams from Registrars and Magistrates on Old-age Pension business are to be transmitted, without prepayment, on production by the transmitter of a signed docket.
(5) The Postmaster to transmit the dockets to the Deputy Postmaster-General, who will claim payment from the Commissioner in the usual way.
(6) The dockets to be in accordance with Form 32.
35. The Old-age Pensions Regulations 1909, being Statutory Rules 1909, No. 47, are hereby revoked.
36. Any claim made or any action taken on forms which are in accordance with the Regulations hereby revoked, may be dealt with as though such forms were provided for in these Regulations.
Form 1 (Reg. 2.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909
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.
* Fill in nature of Office.
† Strike out what is inapplicable.
Form 1a (Reg. 11b.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908–1909.
——
MEDICAL CERTIFICATE FOR PENSION PURPOSES.
(a) Fully describe applicant’s general condition as to his incapacity.(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.”
I,hereby declare that I have this day examinedof a claimant fora 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 claimant’s (e) is such as topermanently incapacitate him for work.I therefore certify that, after full and careful examination of the applicant, I am of opinion that he is permanently incapacitated for work, and is in that respect entitled to a pension under the Invalid and Old-age Pensions Act 1908-1909.Commonwealth Medical Referee.(Address)Date 191
* 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 applicant for work.
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
Deputy Commissioner of Pensions,
——
Form 2 (Reg. 3).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
OLD-AGE PENSION CLAIM.
Attention is directed to the following:—(a) Information for claimants is shown on pages 8 and 9.(b) 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 indictable offence. Penalty: Five years’ imprisonment.
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 1908-1909.My place of abode is atwhere I have resided for a period of and my place or places of abode during the last twelve months have beenThe 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?
Are you single, married, widow, or widower?
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:1pt"><td style="width:36.06%; 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">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-bottom:0pt; 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-bottom:0pt; 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 style="width:20.46%; 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">Places where Births Registered.</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:58.2pt"><td style="width:36.06%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; 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:top"><p style="margin-bottom:0pt; text-align:justify; 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:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:20.46%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; 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:8.25pt"><td colspan="4" style="border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Q</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">uestions</span><span style="font-family:'Times New Roman', serif">—</span></p></td><td colspan="3" style="border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">A</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">nswers</span><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="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:21.6pt; margin-bottom:0pt; text-indent:-21.6pt; 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; text-align:justify; 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="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:21.6pt; margin-bottom:0pt; text-indent:-21.6pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you 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; text-align:justify; 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="padding-right:2pt; 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">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; text-align:justify; 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="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:21.6pt; margin-bottom:0pt; text-indent:-21.6pt; 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-left:21.6pt; margin-bottom:3pt; text-indent:-21.6pt; 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; text-align:justify; 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: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">Q</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">uestions.</span></p></td><td colspan="6" style="border-top:0.75pt solid #000000; border-left: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">A</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">nswers</span><span style="font-family:'Times New Roman', serif">.</span></p></td></tr><tr style="height:22.9pt"><td colspan="6" style="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 the case of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:32.55pt"><td colspan="3" style="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: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="3" style="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-top:6pt; margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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-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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></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-top:6pt; margin-bottom:0pt; text-align:justify; 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></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; text-align:justify; 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></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; text-align:justify; 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:164.2pt"></td><td style="width:50.65pt"></td><td style="width:45.15pt"></td><td style="width:9.4pt"></td><td style="width:74.95pt"></td><td style="width:13.55pt"></td><td style="width:93.15pt"></td><td style="width:4.3pt"></td></tr></tbody></table>
<table cellspacing="0" cellpadding="0" style="width:99.52%; margin-left:0.15pt; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:15.45pt"><td rowspan="3" style="width:46.92%; 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">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; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-top:3pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">A</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">nswers.</span></p></td></tr><tr style="height:28.5pt"><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:middle"><p style="margin-bottom:3pt; 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:28.58%; 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:24.5%; 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:46.92%; 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-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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 style="width:28.58%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; 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; text-align:justify; 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:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; 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><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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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 own more than one house, which of those mentioned above do you live in?</span></p></td><td style="width:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.92%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.58%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:24.5%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr></tbody></table>
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:16.85pt"><td rowspan="3" style="width:46.16%; 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><span style="font-family:'Times New Roman', serif; font-weight:bold; font-variant:small-caps">.</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:middle"><p style="margin-top:3pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">A</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">nswers.</span></p></td></tr><tr style="height:27.1pt"><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:middle"><p style="margin-bottom:3pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(In the ease of married persons, information is required concerning both husband and wife.)</span></p></td></tr><tr style="height:1pt"><td style="width:28.36%; 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">Information concerning Claimant.</span></p></td><td style="width:25.48%; 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">Information concerning Claimant’s Wife or Husband.</span></p></td></tr><tr style="height:1pt"><td style="width:46.16%; 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:3pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">What is the nature and value of such property?</span></p></td><td style="width:28.36%; 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:3pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.48%; 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:3pt; margin-bottom:0pt; text-align:justify; 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:46.16%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:36pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">(Give particulars and value.)</span></p></td><td style="width:28.36%; 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:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.48%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.16%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">Do you own any furniture, vehicles, &c.?</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">(State nature and value of each separately.)</span></p></td><td style="width:28.36%; 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:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.48%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.16%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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 financial institution?</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 names and amounts.)</span></p></td><td style="width:28.36%; 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:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.48%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.16%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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, policy number, amount, and age at which amount payable; also state by whom premiums are paid)</span></p></td><td style="width:28.36%; 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:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.48%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.16%; 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:9pt"><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; font-size:9pt"><span style="font-family:'Times New Roman', serif">(The reply should include information as to money lent, debentures, stock, bank or mining shares, or any other property.)</span></p></td><td style="width:28.36%; 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; text-align:justify; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.48%; 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; text-align:justify; line-height:normal; font-size:9pt"><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 1908-1909, 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 taken 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 a postmistress, or person in charge of a post-office, a police, stipendiary or special magistrate of the Commonwealth or 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 registrar under the Invalid and Old-age Pensions Act 1908-1909, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
——
Form 12 (Reg. 11).
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 13 (Reg. 13).
RECOMMENDATION OF MAGISTRATE.
Hereunder I specify all the material points which I find to be respectively proved, disproved, and unproved or insufficiently proved:—
Claimant 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
Proved.* Disproved.Unproved or Insufficiently Proved.
(3) *Female who has attained the age of 60 years..
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, who has been naturalized for three years, or was naturalized on or before the thirtieth of June, 1910, and claimant is not an Asiatic (except one born in Australia), * 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 recommend that the claim be admitted, and 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.
——
INFORMATION FOR CLAIMANTS APPLYING FOR OLD-AGE PENSIONS.
Subject to the Act, the following persons shall be eligible to receive Old-age Pensions:—
(1) Men who have attained the age of sixty-five years.
(2) Women who have attained the age of sixty years.
(3) Men who, being permanently incapacitated for work, have attained the age of sixty years.
When husband and wife both apply, a separate claim is required for each.
Claimants should supply the information required on pages 1 to 6 of this pension claim. They should not write on any of the other pages.
The claimant should sign his or her name on page 6, opposite the words “Signature of claimant”; also should make and sign the declaration on the same page.
The claim should be sent to the nearest Registrar of Pensions.
With the claim the claimant must send to the Registrar the following:—
(1) Declaration by a person who has known the claimant for twenty years or more (Form 3).
(2) Identification card (Form 4).
If the claimant cannot find a person who has known him for twenty years the declaration may be made by a person who has known him for a shorter period.
Claimants should produce evidence as to age and length of residence in Australia. If they cannot do so, considerable delay may occur before the pensions are granted.
Age may be proved by producing documents such as:—Certificate of birth or baptism; indentures of apprenticeship; military discharge; letter from public department, stating age of a retired public servant; certificate of any public officer, showing age according to immigration record; letter from secretary of lodge, friendly society, or trade union, showing age as appearing in old record; letter from assurance society quoting age in accordance with society’s record; entry in family Bible; marriage certificate; certificate of registration of the birth of claimant’s child (this shows ages of parents at date of child’s birth); shipping discharge or master’s certificate.
Length of residence in Australia may be proved by producing documents such as:—
Certificate of birth or baptism; certificate of registration of the birth of claimant’s child; Lands Office records and receipts for instalments of rent; miner’s rights; marriage certificate; certificate of the registration of the death of the husband, wife, or children; letter from secretary of lodge, friendly society, or trade union showing information in old records; naturalization certificate; benevolent asylum or hospital record; name of claimant in directory; lodge or savings bank pass-books; certificate of church officer showing membership of claimant; certificate of employer.
Men between the ages of 60 and 65 are qualified to receive pensions only if permanently incapacitated for work. Every such person must attach to his claim a medical certificate showing the nature of the incapacity and its permanency, except in a case of accident; where the permanent incapacity is manifest.
The following extracts from the Act are given in order that it may be seen who are qualified to receive pensions:—
15.—(1) Subject to this Act, every person who has attained the age of sixty-five years or who, being permanently incapacitated for work, has attained the age of sixty years shall, whilst in Australia, be qualified to receive an old-age pension.
(2) The Governor-General may by proclamation* declare that the age at which, women shall be qualified to receive an old-age pension shall be sixty-years, and from and after such proclamation the last preceding sub-section shall, as regards women, be read as if the word “sixty” were substituted for the word “sixty-five.”
(3) No old-age pension shall be granted to any person who is under the age of sixty-five years unless and until his claim is recommended in writing by a Deputy Commissioner.
Provided that this sub-section shall not, after proclamation under the last preceding sub-section apply to women.
16.—(1) The following persons shall not be qualified to receive an old-age pension namely:—
(a) Aliens;
(b) Naturalized subjects of the King who have not been naturalized for the period of three years next preceding the date of their pension claims;
(c) Asiatics (except those born in Australia), or aboriginal natives of Australia, Africa, the Islands of the Pacific, or New Zealand.
Provided that a person who is or becomes a naturalized subject of the King on or before the thirtieth day of June One thousand nine hundred and ten shall not be disqualified from receiving an old-age pension by reason only of the fact that he has not been naturalized for the period of three years next preceding the date of his pension claim.
(2) No woman having married one of the persons disqualified by this section shall, in consequence only of such marriage, be or become disqualified to receive a pension.
17. No person shall receive an old-age pension unless—
(a) he is residing in Australia on the date when he makes his claim to the pension;
(b) he has on that date so resided continuously for at least twenty years;
(c) he is of good character;
(d) if a husband, he has not for twelve months or upwards during five years immediately preceding that date, 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; or, if a wife, she has not for twelve months during five years immediately preceding such date, without just cause, deserted her husband, or deserted any of her children being under the age of fourteen years;
(e) the net capital value of his accumulated property, whether in or out of Australia, does not exceed Three hundred and ten pounds;
(f) he has not directly or indirectly deprived himself of property or income in order to qualify for or obtain a pension; and
* This proclamation has been issued.
(g) he has not at any time within six months been refused a pension certificate, except for the reason that he was disqualified on account of his age or for reasons which are not in existence at the time of the further application.
18.—(1.) Continuous residence in Australia shall not be deemed to have been interrupted by occasional absences not exceeding in the aggregate one-tenth of the total period of residence.
(1A) Continuous residence in Australia shall not be deemed to have been interrupted by absence in a Territory under the authority of the Commonwealth, or in any British Possession which becomes a Territory under the authority of the Commonwealth.
(2) A person, whether claimant or pensioner, shall not be deemed to be absent from Australia during any period of absence from Australia if he proves that during that period his home was in Australia, and if married that his wife and family, or his wife (if he has no family), or his family (if his wife is dead), resided in Australia and were maintained by him.
24.—(1) The amount of a pension shall in each case be at such rate as, having regard to all the circumstances of the case, the Commissioner or Deputy Commissioner who determines the pension claim deems reasonable and sufficient, but shall not exceed the rate of Twenty-six pounds per annum in any event, nor shall it be at such a rate as will make the pensioner’s income, together with pension, exceed Fifty-two pounds per annum.
(2) Where the pensioner has accumulated property, the amount of a pension shall be subject to the following deductions:—
(a) One pound for every complete Ten pounds by which the net capital value of the property exceeds Fifty pounds; except where the property includes a home in which the pensioner permanently resides, and which produces no income; and
(b) One pound for every complete Ten pounds by which the net capital value of the property exceeds One hundred pounds, where the property includes a home in which the pensioner permanently resides, and which produces no income.
Provided that, where both husband and wife are pensioners, except where they are living apart pursuant to any decree, judgment, order, or deed of separation, in making the deduction in the case of each of them—
paragraph (a) shall be read with the substitution of Twenty-five pounds for Fifty pounds, and
paragraph (b) shall be read with the substitution of Fifty pounds for One hundred pounds.
25. The net capital value of accumulated property shall be assessed in the prescribed manner, and, unless otherwise prescribed, the following provisions shall apply:—
(a) All real and personal property owned by any person shall be deemed to be his accumulated property:
(b) From the capital value of such accumulated property there shall be deducted all charges or encumbrances lawfully and properly existing on the property, and the residue remaining shall be deemed to be the net capital value of all accumulated property:
(c) Where a valuation has been made for any local authority of any accumulated real property, that valuation, being the last valuation of the property, may for the purposes of this Act be taken to be the capital value of the property unless satisfactory evidence is adduced to the contrary:
(d) In the case of husband and wife, except where they are living apart pursuant to any decree, judgment, order, or deed of separation, the net capital value of the accumulated property of each shall be deemed to be half the total net capital value of the accumulated property of both.
26. In the computation of income—
(a) where any person receives board or lodging or board and lodging, the actual or estimated value or cost of such board or lodging or board and lodging, not exceeding Five shillings per week, shall be included; and
(b) in the case of husband and wife, except where they are living apart pursuant to any decree, judgment, order, or deed of separation, the income of each shall be deemed to be half the total income of both.
4.—(1) “Income” means any moneys, valuable consideration, or profits earned derived or received by any person for his own use or benefit by any means from any source whatever, whether in or out of the Commonwealth, and shall be deemed to include personal earnings, but not any payment—
(a) By way of benefit from any friendly society registered under any Act or State Act or
(b) During illness, infirmity, or old-age from any trade union, provident society, or other society or association, or
(c) By way of allowance under the Miners’ Accident Relief Act 1900 of the State of New South Wales.
Form 2a (Reg. 3).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
INVALID PENSION CLAIM.
Attention is directed to the following:—(a) Information for claimants is shown on pages 7 and 8.(b) 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 indictable offence. Penalty: Five years’ imprisonment.
*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 1908-1909.My place of abode is atwhere I have resided for a period ofand my place or places of abode during the last twelve months have beenThe 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?
Are you single, married, widow, or widower?
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 you maiden name?
Have you at any time applied for an Invalid or Old-age 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:15pt"><td rowspan="3" style="width:47.86%; border-top:0.75pt solid #000000; border-right:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:middle"><p style="margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><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; 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">A</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">nswers.</span></p></td></tr><tr style="height:25.7pt"><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: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">(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:25.44%; 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:10pt"><span style="font-family:'Times New Roman', serif">Information concerning Claimant.</span></p></td><td style="width:26.7%; border-top:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:middle"><p style="margin-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:47.86%; 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-top:6pt; margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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-top:6pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; 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; text-align:justify; 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:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:28.8pt; margin-bottom:0pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><p style="margin-left:43.2pt; margin-bottom:0pt; text-indent:-21.6pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><p style="margin-left:43.2pt; margin-bottom:0pt; text-indent:-21.6pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:47.86%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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 is it situated?</span></p></td><td style="width:25.44%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:26.7%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr></tbody></table>
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:15pt"><td rowspan="3" style="width:46.54%; 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; 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; font-variant:small-caps">Answers.</span></p></td></tr><tr style="height:22.9pt"><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: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">(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:27.68%; 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:25.78%; 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:46.54%; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the nature of the title?</span></p></td><td style="width:27.68%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; 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; text-align:justify; 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:46.54%; 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><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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; 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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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 own more than one house, which of those mentioned above do you live in?</span></p></td><td style="width:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><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 and amounts.)</span></p></td><td style="width:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><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: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:27.68%; 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:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; border-left:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:46.54%; 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><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 lent, debentures, stock, bank, or mining shares, or any other property.)</span></p></td><td style="width:27.68%; 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td style="width:25.78%; 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; text-align:justify; 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 Invaild Pension under the Invalid and Old-age Pensions Act 1908-1909, 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 taken 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 a postmistress, or person in charge of a post-office, a police, stipendiary or special magistrate of the Commonwealth or 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 registrar under the Invalid and Old-age Pensions Act 1908-1909, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
Form 12 (Reg. 11).
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 13a (Reg. 13).
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
Proved.* Disproved.Unproved or Insufficiently Proved.
Length of residence sufficient.................
Proved.* Disproved.Unproved or Insufficiently Proved.
Claimant has become permanently incapacitated whilst in Australia
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 of 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, wife, or children, 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.
* Strike out what is inapplicable.
Claimant is a natural-born or naturalized subject of the King, and claimant is not an Asiatic (except one born in Australia), 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 recommend that the claim be admitted, and 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.
INFORMATION FOR CLAIMANTS APPLYING FOR INVALID PENSIONS.
When husband and wife both apply, a separate claim is required for each.
Claimants should supply the information required on pages 1 to 5 of this pension claim. They should not write on any of the other pages.
The claimant should sign his or her name on page 5, opposite the words “Signature of Claimant”; also should make and sign the declaration on the same page.
The claim should be sent to the nearest Registrar of Pensions.
With the claim the claimant must send to the Registrar the following:—
(1) Declaration by a person who has known the claimant for five years or more (Form 3).
(2) Identification Card (Form 4).
Invalid pensions can be granted only to persons who are permanently incapacitated for work. It is not sufficient that the claimant has been suffering from the results of an accident, or has been incapacitated for work by disease for some time past. The granting of the pension depends upon such accident or disease being permanent in its results. Again, partial incapacity will not suffice, though the Department will not necessarily reject the claim of a person who cannot earn more than a trifling amount.
Except where the incapacity is manifest, the applicant must attach to his claim a medical certificate showing the nature of the incapacity and its permanency.
To constitute permanent incapacity for work, in an application for a pension under the Act, the Medical Certificate must show that the applicant is suffering from either one or other of the following disabilities, or a disability of equal gravity, this table being intended only as a general guide to the classes of cases that may be regarded as fairly within the intention of the Act.
ACCIDENT.
The complete loss of a limb, where such loss renders the applicant permanently incapable of doing work.
The complete destruction of vision.
INVALIDITY.
Nervous System.
Locomotor ataxia (advanced). Cerebro-spinal sclerosis (advanced). Idiocy. Epilepsy-major, with frequent fits. Complete paralysis of a limb, where such paralysis renders the applicant permanently incapable of doing work. Advanced diabetes. Complete loss of vision at mature or advanced age.
Respiratory System.
Advanced tuberculosis or miner’s complaint.
Circulatory System.
Organic disease of the heart, with failure of compensation. Thoracic aneurism.
Genito-Urinary System.
Advanced kidney disease with dropsy.
Senility.
Advanced age (70 years and upwards) with marked degenerative changes.
Chronic articular rheumatism depriving sufferer of use of a limb, and rendering him permanently incapable of doing work.
Unspecified.
Cases of cancer and advanced wasting disease of any kind generally recognized as incurable and permanently unfitting the sufferer for manual or mental work.
The following are extracts from the Act:—
17. No person shall receive………………….pension unless—
(e) The net annual value of his accumulated property, whether in or out of Australia, does not exceed three hundred and ten pounds.
18.—(1) Continuous residence in Australia shall not be deemed to have been interrupted by occasional absences not exceeding in the aggregate one-tenth of the total period of residence.
(1a) Continuous residence in Australia shall not be deemed to have been interrupted by absence in a Territory under the authority of the Commonwealth, or in any British Possession which becomes a Territory under the authority of the Commonwealth.
(2) A person, whether claimant or pensioner, shall not be deemed to be absent from Australia during any period of absence from Australia if he proves that during that period his home was in Australia, and if married that his wife and family, or his wife (if he has no family), or his family (if his wife is dead), resided in Australia and were maintained by him.
20. Subject to this Act, every person above the age of sixteen years who is permanently incapacitated for work, by reason of an accident or by reason of his being an invalid, and who is not receiving an old-age pension, shall, whilst in Australia, be qualified to receive an invalid pension.
21.—(1) The following persons shall not be qualified to receive an invalid pension, namely:—
(a) Aliens.
(b) Asiatics (except those born in Australia), or aboriginal natives of Australia, Africa, the Islands of the Pacific, or New Zealand.
(2) No woman having married one of the persons disqualified by this section shall, in consequence only of such marriage, be or become disqualified to receive a pension.
22. No person shall receive an invalid pension unless—
(a) he is residing in Australia on the date when he makes his claim to the pension;
(b) he has on that date resided in Australia continuously (within the meaning of section eighteen) for at least five years;
(c) he has become permanently incapacitated whilst in Australia;
(d) the accident or invalid state of health was not self-induced, nor in any way brought about with a view to obtaining a pension;
(e) he has no claim against any employer, company, or other person, or body, compellable under private contract or public enactment to adequately maintain or compensate him on account of accident or invalid state of health;
(f) his income or property does not exceed the limits prescribed in the case of applicants for old-age pensions;
(g) he has not directly or indirectly deprived himself of income or property in order to qualify for a pension; and
(h) his relatives, namely, father, mother, husband, wife, or children do not, either severally or collectively, adequately maintain him.
23.—(1) The amount of an invalid pension shall in every case be determined by the Commissioner or Deputy Commissioner, having regard to any income or property possessed by the applicant, and the fact that his relatives contribute to his maintenance, and the fact also of his having received compensation from any source in respect of any injury.
(2) The Commissioner or Deputy Commissioner shall in all cases of invalidity, and also in cases of accident where the permanent incapacity for work is not manifest, direct an examination of the claimant to be made by a duly qualified medical practitioner, who shall certify whether in his opinion the claimant is permanently incapacitated for work, and shall state the grounds upon which his opinion is founded.
24.—(1) The amount of a pension shall in each case be at such rate as, having regard to all the circumstances of the case, the Commissioner or Deputy Commissioner who determines the pension claim deems reasonable and sufficient, but shall not exceed the rate of Twenty-six pounds per annum in any event, nor shall it be at such a rate as will make the pensioner’s income, together with pension, exceed Fifty-two pounds per annum.
(2) Where the pensioner has accumulated property, the amount of a pension shall be subject to the following deductions:—
(a) One pound for every complete Ten pounds by which the net capital value of the property exceeds Fifty pounds; except where the property includes a home in which the pensioner permanently resides, and which produces no income; and
(b) One pound for every complete Ten pounds by which the net capital value of the property exceeds One hundred pounds, where the property includes a home in which the pensioner permanently resides, and which produces no income.
Provided that, where both husband and wife are pensioners, except where they are living apart pursuant to any decree, judgment, order, or deed of separation, in making the deduction in the case of each of them—
paragraph (a) shall be read with the substitution of Twenty-five pounds for Fifty pounds, and
paragraph (b) shall be read with the substitution of Fifty pounds for One hundred pounds.
25. The net capital value of accumulated property shall be assessed in the prescribed manner, and, unless otherwise prescribed, the following provisions shall apply:—
(a) All real and personal property owned by any person shall be deemed to be his accumulated property:
(b) From the capital value of such accumulated property there shall be deducted all charges or encumbrances lawfully and properly existing on the property, and the residue remaining shall be deemed to be the net capital value of all accumulated property:
(c) Where a valuation has been made for any local authority of any accumulated real property, that valuation, being the last valuation of the property, may for the purposes of this Act be taken to be the capital value of the property unless satisfactory evidence is adduced to the contrary:
(d) In the case of husband and wife, except where they are living apart pursuant to any decree, judgment, order or deed of separation, the net capital value of the accumulated property of each shall be deemed to be half the total net capital value of the accumulated property of both.
26. In the computation of income—
(a) where any person receives board or lodging or board and lodging, the actual or estimated value or cost of such board or lodging or board and lodging, not exceeding Five shillings per week, shall be included; and
(b) in the case of husband and wife, except where they are living apart pursuant to any decree, judgment, order, or deed of separation, the income of each shall be deemed to be half the total income of both.
4.—(1) “Income” means any moneys, valuable consideration, or profits earned derived or received by any person for his own use or benefit by any means from any source whatever, whether in or out of the Commonwealth, and shall be deemed to include personal earnings, but not any payment—
(a) By way of benefit from any friendly society registered under any Act or State Act, or
(b) During illness, infirmity, or old-age from any trade union, provident society, or other society or association, or
(c) By way of allowance under the Miners’ Accident Relief Act 1900 of the State of New South Wales.
Form 3 (Reg. 3).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
DECLARATION OF 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 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—Six months’ imprisonment.
——
Name, Address, and Occupation of Claimant.
I, do solemnly and sincerely declare that the (Name, occupation, and address 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, and in what places?Are you related to claimant?Could the claimant have been absent for any considerable period from Australia without your being acquainted with the fact?(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 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 incapaciated 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 19 before me,*†………………………………………………………………………
Signature of Declarant.
* Person before whom this declaration is taken 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 a postmistress, or person in charge of a post-office, a police, stipendiary or special magistrate of the Commonwealth or 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 registrar under the Invalid and Old-age Pensions Act 1908-1909, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:86.4pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">F</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">orm </span><span style="font-family:'Times New Roman', serif">4 (Reg. 3.)</span></p></td><td rowspan="7" style="width:79.2pt; height:0pt; margin-left:auto; writing-mode:tb-rl; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:0pt; 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">Payment to be made in future</span><br><span style="font-family:'Times New Roman', serif">at</span><span style="font-family:'Times New Roman', serif"> </span><span style="font-family:'Times New Roman', serif">The last payment made at this office was due on “Pension Thursday,” the</span><span class="CommentReference"></span><span style="font-family:'Times New Roman', serif"></span><br><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">191</span><span style="font-family:'Times New Roman', serif"></span></p><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">Signed</span></p><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:right; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Postmaster at</span><span style="width:12.75pt; display:inline-block"> </span><span style="font-family:'Times New Roman', serif">Date</span></p></div></td><td rowspan="7" style="width:65.7pt; height:0pt; margin-left:auto; writing-mode:tb-rl; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:0pt; 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">Payment to be made in future</span><br><span style="font-family:'Times New Roman', serif">at</span><span style="font-family:'Times New Roman', serif"> </span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">The last payment made at this office was due on “Pension Thursday,” the</span><span style="font-family:'Times New Roman', serif"></span><br><span style="font-family:'Times New Roman', serif">191</span></p><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">Signed</span></p><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:right; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Postmaster at </span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">Date</span></p></div></td><td rowspan="7" style="width:82.8pt; height:0pt; margin-left:auto; writing-mode:tb-rl; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:0pt; 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">Payment to be made in future</span><br><span style="font-family:'Times New Roman', serif">at </span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">The last payment made at this office was due on “Pension Thursday,” the</span><br><span style="font-family:'Times New Roman', serif">191</span></p><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">Signed</span></p><p style="margin-right:5.65pt; margin-left:5.65pt; margin-bottom:0pt; text-align:right; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Postmaster at</span><span style="font-family:'Times New Roman', serif"> </span><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">Date</span></p></div></td></tr><tr><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Pension Certificate No.</span></p></td></tr><tr><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; 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">Pensioner’s Name</span></p></td></tr><tr><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:14.4pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Pension at the rate of fortnightly granted, payable at</span></p></td></tr><tr><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-left:7.2pt; margin-bottom:0pt; text-indent:14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">The Pensioner was first entitled to payment on “Pension Thursday,” the </span><span style="width:13.02pt; text-indent:0pt; display:inline-block"></span><span style="font-family:'Times New Roman', serif">191 for the fortnight commencing on that date.</span></p></td></tr><tr><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-right:14.4pt; margin-bottom:0pt; text-align:right; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-style:italic">Deputy Commissioner.</span></p></td></tr><tr style="height:30.6pt"><td style="width:188.1pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-indent:85.5pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Date</span></p></td></tr></tbody></table>
<table cellspacing="0" cellpadding="0" style="width:465.2pt; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:29.9pt"><td colspan="5" style="width:447.3pt; border-top:0.75pt solid #000000; border-bottom:0.75pt solid #000000; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-top:6pt; margin-left:21.6pt; margin-bottom:6pt; text-indent:-21.6pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">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. [</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">The Card should not be</span><span style="font-family:'Times New Roman', serif"> </span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Folded.]</span></p><p style="margin-left:3.25pt; margin-bottom:0pt; text-align:justify; 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="10" style="width:50pt; 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; font-size:10pt"><span style="font-family:'Times New Roman', serif">F</span><span style="font-family:'Times New Roman', serif; font-variant:small-caps">orm</span><span style="font-family:'Times New Roman', serif"> 4. (Reg. 3.) PARTICULARS FOR IDENTIFICATION OF PENSIONER.</span></p></div></td><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Name of Claimant in full</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td><td colspan="2" rowspan="10" style="width:42.05pt; 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; font-size:10pt"><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:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Date and Place of Birth</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Postal Address</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Last Occupation</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="width:361.15pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Number of Children</span><span style="width:20.81pt; 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">of whom</span><span style="width:0.17pt; display:inline-block"> </span><span style="width:36pt; display:inline-block"></span><span style="font-family:'Times New Roman', serif">are living</span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Name of Claimant’s Father</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Maiden Name of Claimant’s Mother</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Signature of Claimant</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:6.1pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(or his witnessed mark).</span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td style="width:211.1pt; padding-right:2pt; 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"></span></p></td><td style="width:90.95pt; padding-right:2pt; 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"></span></p></td><td style="width:51.1pt; padding-right:2pt; 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; font-style:italic">Registrar.</span></p></td></tr><tr style="height:0pt"><td style="width:54pt"></td><td style="width:215.1pt"></td><td style="width:94.95pt"></td><td style="width:55.1pt"></td><td style="width:38.95pt"></td><td style="width:7.1pt"></td></tr></tbody></table>
Form 5 (Reg. 6).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
The 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 6 (Reg. 7).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age-Pensions Act 1908-1909.
——
From the Registrar of Pensions at
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 “Old-age Pensions.”
Registrar.
Date
*Strike out what is inapplicable.
——
Questions on this page only to be answered in case claimant is applying for Invalid Pension.
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:1pt"><td colspan="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-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">replies.</span></p></td></tr><tr style="height:1pt"><td colspan="3" 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-top:6pt; margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What is the claimant’s state of health; or what, in general terms, is the nature of the invalidity or accident?</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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" 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">Does it incapacitate claimant for any work?</span></p><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Have you any reason to believe that it was self-induced, or in any way brought about with a view to obtaining pension?</span><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-left:36pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, state your 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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is claimant confined to bed or to the house, or is he able to leave the house?</span><span style="width:21.04pt; text-indent:0pt; display:inline-block"></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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-left:36pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State which.)</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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Did claimant’s incapacity become permanent in Australia?</span><span style="width:17.09pt; text-indent:0pt; display:inline-block"></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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What was claimant’s last occupation?</span><span style="width:73.95pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">............</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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How long ago was this?</span><span style="width:128.9pt; text-indent:0pt; font-family:'Lucida Console', monospace; display:inline-block">.....................</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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" style="border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">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?</span><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-left:36pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(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; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:1pt"><td colspan="3" 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Do you believe that claimant is adequately maintained by his relatives?</span><span style="width:3.09pt; text-indent:0pt; display:inline-block"></span></p><p style="margin-left:36pt; margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(State your reasons.)</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; text-align:justify; 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="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:3pt; 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="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Replies.</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-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">In your opinion, what is claimant’s age ?</span></p><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What documentary evidence (if any) as to age have you seen?</span></p><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Evidence should be produced if possible.)</span></p></td><td colspan="3" style="padding-right:2pt; 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"></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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Has claimant lived continuously in Australia for</span><br><span style="font-family:'Times New Roman', serif">{ *20 years or more/*5 years or more} and is now residing in Australia.</span></p></td><td colspan="3" style="padding-right:2pt; 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"></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: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">(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.)</span></p></td><td colspan="3" style="padding-right:2pt; 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"></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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What documentary evidence (if any) as to length of residence have you seen?</span></p><p style="margin-left:50.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(Evidence should be produced if possible.)</span></p></td><td colspan="3" style="padding-right:2pt; 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"></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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Is the claimant a natural-born British subject?</span></p></td><td colspan="3" style="padding-right:2pt; 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"></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:14.4pt; 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 the claimant is not a natural-born British subject, when and where was claimant naturalized?</span></p></td><td colspan="3" style="padding-right:2pt; 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"></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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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:50.4pt; 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="3" style="padding-right:2pt; 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"></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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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="3" style="padding-right:2pt; 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"></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-align:justify; line-height:normal; font-size:10pt"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:21"><img src="image.021.png" width="11" height="234" alt="" style="margin-top:11.18pt; margin-left:37.47pt; position:absolute"></span><span style="font-family:'Times New Roman', serif">Is claimant of good character?</span></p></td><td colspan="3" style="padding-right:2pt; 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"></span></p></td></tr><tr style="height:1pt"><td rowspan="2" style="width:9.34%; height:1pt; margin-right:auto; margin-left:auto; writing-mode:tb-rl; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:middle; -moz-transform:rotate(180deg); -ms-transform:rotate(180deg); overflow:hidden; transform:rotate(180deg); -webkit-transform:rotate(180deg)"><div style="height:1pt; margin-right:auto; 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 colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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: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 you have any knowledge of a maintenance order, please say so.)</span></p></td><td style="vertical-align:top"></td></tr><tr style="height:73.05pt"><td colspan="3" style="border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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 style="vertical-align:top"></td></tr><tr style="height:0pt"><td style="width:42.5pt"></td><td style="width:170.95pt"></td><td style="width:22.15pt"></td><td style="width:81.4pt"></td><td style="width:138.35pt"></td></tr></tbody></table>
* 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 rowspan="3" style="width:48.24%; 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; font-variant:small-caps">Questions</span><span style="font-family:'Times New Roman', serif; font-weight:bold; font-variant:small-caps">.</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-top:3pt; margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Replies.</span></p></td></tr><tr style="height:1pt"><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-top:3pt; margin-bottom:3pt; 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:1pt"><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">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-top:3pt; margin-bottom:3pt; 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 style="width:48.24%; 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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><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 to be quoted. Also state if bank book produced.)</span></p></td><td colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; 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 colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Does the property include a home in which the claimant permanently resides and which produces no income?</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 claimant has more than one house indicate that which is the home, and state its value and encumbrance.)</span></p></td><td colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><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 colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Does the claimant receive free board or lodging?</span></p><p style="margin-bottom:0pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">(If so, give particulars.)</span></p></td><td colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">How has claimant been maintained during the last twelve months?</span></p></td><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"></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; text-align:justify; 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:48.24%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What amount of other income or means of support has the claimant?</span></p></td><td colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; border-right:0.75pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><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 colspan="2" 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; text-align:justify; 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; text-align:justify; 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:48.24%; 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:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">What property has claimant parted with during recent years?</span></p></td><td colspan="2" style="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; text-align:justify; 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; border-bottom:0.75pt solid #000000; padding-right:2pt; padding-left:1.62pt; 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"></span></p></td></tr><tr style="height:1pt"><td colspan="2" style="border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:3pt; 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; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:3pt; text-align:center; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif; font-variant:small-caps">Replies.</span></p></td><td style="border-top:0.75pt solid #000000; vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><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="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Would pension be probably misspent in drink or otherwise?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Are husband and wife living together?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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, are they living apart pursuant to any decree, judgment, order, or deed of separation?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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 his wife applied for or been granted a pension, or will she soon apply?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; 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 her husband applied for or been granted a pension, or will he soon apply?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Do you know any reason why pension should not be granted?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">At what Post Office should pension, granted, be paid?</span></p></td><td colspan="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:1pt"><td colspan="2" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:14.4pt; margin-bottom:0pt; text-indent:-14.4pt; text-align:justify; line-height:normal; font-size:10pt"><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="2" style="padding-right:2pt; 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"></span></p></td><td style="vertical-align:top"></td></tr><tr style="height:0pt"><td style="width:219.65pt"></td><td style="width:30.95pt"></td><td style="width:94.1pt"></td><td style="width:107.2pt"></td><td style="width:3.45pt"></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 reply to the questions on pages 2 to 5 of 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 7 (Reg. 8).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 the reply be written hereunder.
Registrar.
Date
——
From
To the Registrar of Pensions at
Signed
Date
Form 8 (Reg. 8).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
CONFIDENTIAL REPORT—BANK.
From the Registrar of Pensions at
To the Manager, Bank of
The persons named in the attached Schedule are 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.
To the best of my knowledge and belief, I certify, after due inquiry, that the particulars of money or securities shown in the Schedule above are correct.
Manager.
Date
Form 9 (Reg. 8).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 full)
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
‡ According to shipping record claimant’s age was at the following date, viz,:—
Full Names of Children.
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 is shown above.
‡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.
‡ To be filled in in Deputy Commissioner’s Office.
§ State also places of registration if not registered at places where born.
Form 10 (Reg. 9).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
NOTICE TO CLAIMANT TO ATTEND INVESTIGATION.
To
Address
Take notice that the investigation of your Pension Claim will be made on day, the day of 19 , at the Court-house* 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.
* Alter this word if investigation is to be made at a place other than a Court-house.
Form 11 (Reg. 9).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
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.
I have the honour to be,
Sir,
Your most obedient Servant,
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 15 (Reg. 14).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 16 (Reg. 15).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 17 (Reg 17.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 fortnightly payment in advance as from
Deputy Commissioner of Pensions.
Place
Date 19 .
Form 18 (Reg. 17.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 19. (Reg. 18.)
PENSION CERTIFICATE.
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 191 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 27 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.
<table cellspacing="0" cellpadding="0" style="width:100%; margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:37.3pt"><td rowspan="10" style="width:8.98%; height:37.3pt; 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:37.3pt; margin-left:auto; writing-mode:tb-rl; overflow:hidden"><p style="margin-right:8.5pt; margin-left:8.5pt; margin-bottom:3pt; text-indent:21.6pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">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 23rd March, 1911, for the fortnight commenced on that date is paid, the date stamp must be placed in the space in which the date 23rd March, 1911, is printed.</span></p><p style="margin-top:6pt; margin-right:5.65pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></div></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Pension Certificate Number</span></p></td><td colspan="3" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="width:27.5pt; display:inline-block"></span></p><p style="margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="width:27.5pt; display:inline-block"></span><span style="width:36pt; display:inline-block"></span><span style="font-family:'Times New Roman', serif">Pensioner’s Name</span></p><p style="margin-top:6pt; margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif"></span></p></td><td colspan="5" rowspan="3" style="border-bottom:1.5pt solid #000000; padding-right:2pt; 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"></span></p><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span><span style="font-family:'Times New Roman', serif">pence, payable at</span></p><p style="margin-top:6pt; margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif"></span></p><p style="margin-top:6pt; margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="height:0pt; margin-top:-6pt; display:block; position:relative; z-index:25"><img src="image.024.png" width="11" height="26" alt="" style="margin-top:9.77pt; margin-left:55.58pt; position:absolute"></span><span style="font-family:'Times New Roman', serif">Witness to</span><br><span style="font-family:'Times New Roman', serif">Mark</span></p></td></tr><tr style="height:37.3pt"><td colspan="6" style="padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">Fortnightly Rate</span><span style="width:33.67pt; 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">shilling</span></p></td></tr><tr style="height:37.3pt"><td colspan="6" style="border-bottom:1.5pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-left:8.5pt; margin-bottom:0pt; line-height:normal; font-size:10pt"><span style="height:0pt; margin-top:-6pt; display:block; position:relative; z-index:24"><img src="image.025.png" width="11" height="30" alt="" style="margin-top:8.68pt; margin-left:103.32pt; position:absolute"></span><span style="font-family:'Times New Roman', serif">Pensioner’s Signature</span><br><span style="font-family:'Times New Roman', serif">(or witnessed mark)</span></p></td></tr><tr style="height:37.3pt"><td style="width:8.98%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:2pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">14 July, 1910.</span></p></td><td style="width:9.52%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">6 Oct., 1910.</span></p></td><td colspan="2" style="border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">29 Dec, 1910.</span></p></td><td style="width:9.52%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">23 Mar., 1911.</span></p></td><td style="width:8.9%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">15 June, 1911.</span></p></td><td style="width:8.88%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">7 Sept., 1911.</span></p></td><td style="width:8.92%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">30 Nov., 1911.</span></p></td><td style="width:8.98%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">22 Feb., 1912.</span></p></td><td style="width:9.14%; border-top:1.5pt solid #000000; border-right:0.75pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">16 May, 1912.</span></p></td><td style="width:8.66%; border-top:1.5pt solid #000000; border-left:0.75pt solid #000000; border-bottom:1.5pt solid #000000; padding-right:2pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">8 Aug., 1912.</span></p></td></tr><tr style="height:40.45pt"><td style="width:8.98%; border-top:1.5pt 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:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">28 July, 1910.</span></p></td><td style="width:9.52%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">20 Oct., 1910.</span></p></td><td colspan="2" style="border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">12 Jan., 1911.</span></p></td><td style="width:9.52%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">6 Apr., 1911.</span></p></td><td style="width:8.9%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">29 June, 1911.</span></p></td><td style="width:8.88%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">21 Sept., 1911.</span></p></td><td style="width:8.92%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">14 Dec, 1911.</span></p></td><td style="width:8.98%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">7 Mar., 1912.</span></p></td><td style="width:9.14%; border-top:1.5pt solid #000000; 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-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">30 May, 1912.</span></p></td><td style="width:8.66%; border-top:1.5pt 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:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">22 Aug., 1912.</span></p></td></tr><tr style="height:39.55pt"><td style="width:8.98%; 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:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">11 Aug., 1910.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">3 Nov., 1910.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">28 Jan., 1911.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">20 Apr., 1911.</span></p></td><td style="width:8.9%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">13 July, 1911.</span></p></td><td style="width:8.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">5 Oct., 1911.</span></p></td><td style="width:8.92%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">28 Dec, 1911.</span></p></td><td style="width:8.98%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">21 Mar., 1912.</span></p></td><td style="width:9.14%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">13 June, 1912.</span></p></td><td style="width:8.66%; 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:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">5 Sept., 1912.</span></p></td></tr><tr style="height:44.5pt"><td style="width:8.98%; 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:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">25 Aug., 1910.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">17 Nov., 1910.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">9 Feb., 1911.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">4 May, 1911.</span></p></td><td style="width:8.9%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">27 July, 1911.</span></p></td><td style="width:8.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">19 Oct., 1911.</span></p></td><td style="width:8.92%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">11 Jan., 1912.</span></p></td><td style="width:8.98%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">4 Apr., 1912.</span></p></td><td style="width:9.14%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">27 June, 1912.</span></p></td><td style="width:8.66%; 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:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">19 Sept., 1912.</span></p></td></tr><tr style="height:44.5pt"><td style="width:8.98%; 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:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">8 Sept., 1910.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">1 Dec, 1910.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">23 Feb., 1911.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">18 May, 1911.</span></p></td><td style="width:8.9%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">10 Aug., 1911.</span></p></td><td style="width:8.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">2 Nov., 1911.</span></p></td><td style="width:8.92%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">25 Jan., 1912.</span></p></td><td style="width:8.98%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">18 Apr., 1912.</span></p></td><td style="width:9.14%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">11 July, 1912.</span></p></td><td style="width:8.66%; 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:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">3 Oct., 1912.</span></p></td></tr><tr style="height:35.5pt"><td style="width:8.98%; 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:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">22 Sept., 1910.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">15 Dec., 1910.</span></p></td><td colspan="2" style="border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">9 Mar., 1911.</span></p></td><td style="width:9.52%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">1 June, 1911.</span></p></td><td style="width:8.9%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">24 Aug., 1911.</span></p></td><td style="width:8.88%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">16 Nov., 1911.</span></p></td><td style="width:8.92%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">8 Feb., 1912.</span></p></td><td style="width:8.98%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">2 May, 1912.</span></p></td><td style="width:9.14%; border:0.75pt solid #000000; padding-right:1.62pt; padding-left:1.62pt; vertical-align:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">25 July, 1912.</span></p></td><td style="width:8.66%; 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:top"><p style="margin-top:6pt; margin-bottom:0pt; text-align:center; line-height:normal; font-size:9pt"><span style="font-family:'Times New Roman', serif">17 Oct., 1912.</span></p></td></tr><tr style="height:35.5pt"><td colspan="11" style="border-top:0.75pt solid #000000; padding-right:2pt; padding-left:2pt; vertical-align:top"><p style="margin-bottom:0pt; text-indent:21.6pt; text-align:justify; line-height:normal; font-size:10pt"><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">1908-1909 includes the following provision:—</span></p><p style="margin-bottom:3pt; text-indent:43.2pt; text-align:justify; line-height:normal; font-size:10pt"><span style="font-family:'Times New Roman', serif">“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.”</span></p></td></tr><tr style="height:0pt"><td style="width:63pt"></td><td style="width:63pt"></td><td style="width:66.85pt"></td><td style="width:33.15pt"></td><td style="width:33.7pt"></td><td style="width:66.85pt"></td><td style="width:62.5pt"></td><td style="width:62.35pt"></td><td style="width:62.6pt"></td><td style="width:63.05pt"></td><td style="width:64.15pt"></td><td style="width:60.8pt"></td></tr></tbody></table>
Form 20 (Reg. 20.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
APPLICATION FOR DUPLICATE CERTIFICATE.
To the Deputy Commissioner of Pensions at
I,
of
being a Pensioner under the aforesaid Act, hereby make application for a duplicate Pension Certificate in lieu of the original Certificate No. ; and in support of the application I hereby declare as follows:—
1. The original Certificate was duly issued to me as Pensioner, and has been lost [or, as the case may be, destroyed].
2.*
† I have made diligent search for the lost Certificate, but have been unable to find it.
I do hereby solemnly declare that this statement is true.
Declared by the said at this 19 , before me—
Applicant.
‡§
* If destroyed, state when and how.
† If lost.
‡ The person before whom this declaration is taken 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 a postmistress, or person in charge of a post-office, a police, stipendiary or special magistrate of the Commonwealth or 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 registrar under the Invalid and Old-age Pensions Act 1908-1909, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
Form 21 (Reg. 21.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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:—
Signature of Applicant
I beg to report to the Deputy Commissioner of Pensions at
that I have authorized the transfer from to
The last payment made at this office was due on “Pension Thursday,” the 191 .
Postmaster or Paying Officer.
Form 22 (Reg. 24.)
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr style="height:15.3pt"><td style="width:116.1pt; padding-right:5.4pt; padding-left:5.4pt; 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">Pension Certificate No.</span></p></td><td style="width:227.7pt; padding-right:5.4pt; padding-left:5.4pt; 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">COMMONWEALTH OF AUSTRALIA.</span></p></td><td style="width:86.05pt; padding-right:5.4pt; padding-left:5.4pt; 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">Post Office Date Stamp to be</span></p></td></tr><tr><td style="width:116.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:227.7pt; padding-right:5.4pt; padding-left:5.4pt; 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 rowspan="2" style="width:86.05pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:26"><img src="image.026.png" width="43" height="54" alt="" style="margin-top:4.07pt; margin-left:22.27pt; position:absolute"></span><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr style="height:35.55pt"><td style="width:116.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:227.7pt; padding-right:5.4pt; padding-left:5.4pt; 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">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; font-variant:small-caps">1908-1909.</span></p><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><tr><td style="width:116.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:227.7pt; padding-right:5.4pt; padding-left:5.4pt; 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">RECEIPT FOR INSTALMENT OF PENSION.</span></p></td><td style="width:86.05pt; padding-right:5.4pt; padding-left:5.4pt; 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">placed in this square.</span></p></td></tr></tbody></table>
I acknowledge to have received, the sum of £ : : , being Pension payable in accordance with Pension Certificate numbered as above for the fortnight ended
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).
Form 23 (Reg. 24.)
<table cellspacing="0" cellpadding="0" style="margin-bottom:0pt; border-collapse:collapse"><tbody><tr><td style="width:107.1pt; padding-right:5.4pt; padding-left:5.4pt; 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">Pension Certificate No.</span></p></td><td style="width:241.2pt; padding-right:5.4pt; padding-left:5.4pt; 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"></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; font-size:10pt"><span style="font-family:'Times New Roman', serif">Post Office Date Stamp to be</span></p></td></tr><tr><td style="width:107.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:241.2pt; padding-right:5.4pt; padding-left:5.4pt; 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">COMMONWEALTH OF AUSTRALIA.</span></p></td><td rowspan="4" style="width:81.55pt; padding-right:5.4pt; padding-left:5.4pt; vertical-align:top"><p style="margin-bottom:0pt; text-align:justify; line-height:normal; font-size:10pt"><span style="height:0pt; text-align:left; display:block; position:relative; z-index:27"><img src="image.027.png" width="69" height="74" alt="" style="margin-top:2.28pt; margin-left:11.23pt; position:absolute"></span><span style="font-family:'Times New Roman', serif"></span></p></td></tr><tr><td style="width:107.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:241.2pt; padding-right:5.4pt; padding-left:5.4pt; 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><tr style="height:16.15pt"><td style="width:107.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:241.2pt; padding-right:5.4pt; padding-left:5.4pt; 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">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">1908-1909.</span></p></td></tr><tr style="height:21.55pt"><td style="width:107.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:241.2pt; padding-right:5.4pt; padding-left:5.4pt; 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><tr><td style="width:107.1pt; padding-right:5.4pt; padding-left:5.4pt; 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"></span></p></td><td style="width:241.2pt; padding-right:5.4pt; padding-left:5.4pt; 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">RECEIPT FOR INSTALMENT OF PENSION.</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; font-size:10pt"><span style="font-family:'Times New Roman', serif">placed in this square.</span></p></td></tr></tbody></table>
I acknowledge to have received, for the benefit of the Pensioner, the sum of £ : : , being Pension payable in accordance with Pension Certificate numbered as above for the fortnight ended 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.
Form 24 (Reg. 26.)
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
APPLICATION FOR PAYMENT OF FORFEITED INSTALMENT.
I,*
of* , being the Pensioner [or, as the case may be, the authorized payee] under Pension Certificate No. apply for payment of the forfeited instalment (or instalments) which was (or were) due for the period of weeks ended 19 , and which amounts (or amount) to £
I declare that the information given in reply to the following questions is true and correct:—
(a) Has pensioner during any portion of the period referred to been an inmate of a Benevolent Asylum, Hospital, or Asylum for the Insane?
(a) †
(b) Why was the amount not applied for in due time?
(b) ‡
I do hereby declare that this statement is true and correct in every particular.
† If pensioner was an inmate, give name of institution and dates of admission and discharge.
‡ Here set out briefly but clearly the reason why the instalment or instalments not applied for in due time.
§ The person before whom this declaration is taken 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 a postmistress, or person in charge of a post-office, a police, stipendiary or special magistrate of the Commonwealth or 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 registrar under the Invalid and Old-age Pensions Act 1908-1909, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
C.9525.
B
Form 25 (Reg. 26).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
WAIVER OF FORFEITURE.
I hereby grant this Warrant waiving forfeiture of the instalment of the pension which was payable to pursuant to Pension Certificate No. for the fortnight ended 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.
Form 26 (Reg. 28).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
APPLICATION FOR WARRANT AUTHORIZING PAYMENT TO PERSON OTHER THAN THE PENSIONER.
Note.—A Warrant cannot be issued in respect of any Pensioner 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
(1) Full name, occupation, and address of applicant.(2) Full name of pensioner.(3) Full name, occupation, and address of proposed payee.(4) Set out briefly but clearly the grounds.(5) Proposed payee.
I, (1)hereby apply for a Warrant under the Act directing that until the Warrantis cancelled all instalments of the Pension payable to (2)pursuant to Pension Certificate No.may be paid to (3)for the benefit of the Pensioner, on the grounds (4)Dated at this day of 19Applicant.I consent hereto. I am already the holder of Warrants for Payment ofPensions in the following cases, and no others:— (5)* I hereby certify that the Pensioner and the proposed Payee are personallyknown to me, and that owing tothe Pensioner is now unable, and, in my opinion, will be unable for a periodof† to collect the Pension instalments, and thatthe proposed Payee is a suitable person for the purpose.‡To the Deputy Commissioner atI am satisfied that this Application should be granted.Registrar of Pensions atDate
* This certificate must be signed by one of the following persons:—A postmaster or a postmistress, or person in charge of a post-office, a police, stipendiary or special magistrate of the Commonwealth or 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 registrar under the Invalid and Old-age Pensions Act 1908-1909, a minister of religion, or an officer of the Commonwealth Department of the Treasury.
† State how long inability will probably continue.
‡ State title under which certificate is given.
Form 27 (Reg. 28).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
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 28 (Reg. 30).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
PENSIONER IN CHARITABLE INSTITUTION.
I report that of who is a (Insert name of Pensioner.) (Insert address of Pensioner.)
Pensioner under the above-named Act, was admitted to the
(Insert name of Institution.) on the day of 19 , and that he is still an inmate.
(Pension Certificate No. * Payable at )
Signature
Office held by person reporting
Date
To the Postmaster or Officer paying Old-age Pensions at
Noted and forwarded to the Deputy Commissioner of Pensions.
Signature
Postmaster at
Date
* The number should be filled in if the Pension Certificate has come under the notice of the person reporting.
Form 29 (Reg. 31)
COMMONWEALTH OF AUSTRALIA
——
The Invalid and Old-age Pensions Act 1908-1909.
——
DISCHARGE OF PENSIONER FROM CHARITABLE INSTITUTION.
I certify that who was admitted to the (Insert name and address of Pensioner.) was discharged therefrom on the day (Insert name of Institution.)
of 19
Signature
Office held by person reporting
Date
To the Postmaster or Officer Paying Old-age Pensions at
Note.—This Notice must be pinned by the Postmaster to the receipt for the first instalment paid after the discharge.
Form 30 (Reg. 32).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
NOTICE OF DEATH.
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 to have been a Pensioner under the above-named Act whose pension was paid at
District Registrar of Births, Deaths, and Marriages, Or Official charged with duty of registering Deaths.
Address of the Official making this report
Date 19
A regulation under the Invalid and Old-age Pensions Act 1908-1909 authorizes the official registering a death to inquire, when registering the death of any person whether the deceased was a Pensioner under the Act, and, if so, to notify the Deputy Commissioner. As invalid pensions are granted to persons of 16 years and upwards who are permanently incapacitated, inquiry should be made in all cases above the age of 16 years.
* Insert full name and last address; also any other available particulars likely to assist in identification.
Form 31 (Reg. 33).
COMMONWEALTH OF AUSTRALIA.
——
The Invalid and Old-age Pensions Act 1908-1909.
——
REQUISITION FOR FORMS.
In order to guard against any waste of Forms, &c., it is requested that care be exercised to see that reasonable quantities only, having regard to actual requirements, are applied for.
I beg to apply for the following printed Forms for the use of this Office.
(Place)
Signature
Office
Date 19 .
Approximate No. in Stock.
No. now required.
Distinguishing No., &c., of Form.
1. Declaration by Officer. (Not supplied to Registrars, Postmasters, or Paying Officers)
2. Old-age Pension Claim
2a. Invalid Pension Claim
3. Declaration by person who has known Claimant, &c.
4. Identification Card
5. District Register
6. Police Report
7. Confidential Reports—General
8. Confidential Report—Bank
9. Search for particulars as to age or arrival in Australia
10. Notice to Claimant to attend Investigation
11. Notice to Magistrate
12. Registrar’s Report to Magistrate. (This is printed at end of Form 2.)
13. Recommendation of Magistrate. (Old-age Pension Claim. (This is printed at end of Form 2.)
Approximate No. in Stock.
No. now required.
Distinguishing No., &c., of Form.
13a. Recommendation of Magistrate. (Invalid Pension Claim.) This is printed at end of Form 2a.
15. Notice of Intention to Adduce Fresh Evidence
16. Appeal to Minister
17. Notice of the Grant of a Pension (not supplied to Registrars, Postmasters, or Paying Officers)
18. Notice of Rejection of Claim (not supplied to Registrars, Postmasters, or Paying Officers)
19. Pension Certificate (not supplied to Registrars, Postmasters, or Paying Officers)
20. Application for Duplicate Certificate
21. Application for Change of Place of Payment
22. Receipt to be given by Pensioner for Instalment of Pension
23. Receipt to be given by Warrantee on behalf of Pensioner for Instalment of Pension
24. Application for Payment of Forfeited Instalment
25. Waiver of Forfeiture
20. Application for Warrant authorizing payment to person other than Pensioner
27. Warrant for Payment to person other than Pensioner (not supplied to Registrars, Postmasters, or Paying Officers)
28. Pensioner in Charitable Institution
29. Discharge of Pensioner from Charitable Institution
30. Notice of Death
31. Requisition for Forms
32. Postage and Telegram Docket, for Registrars only.
32. Postage and Telegram Docket (in book form, for Postmasters only).
33. Examiner’s Report (not supplied to Registrars, Postmasters, or Paying Officers).
Form “A” Register of Payments.
„ “B” Pension Pay Docket in Book Form.
„ “C” Record of Postage Stamps.
„ “D” Memorandum for use by Postmasters.
Instructions to Postmasters, as issued by Commissioner of Pensions.
Envelopes, 9 in. x 5 in. for use of Registrars.
Form 32 (Reg. 34).
COMMONWEALTH OF AUSTRALIA.
——
Department of the Treasury.
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OLD-AGE PENSIONS.
Place
Date
Number of Articles
Image unavailable in extracted text*Postage due £ : :
*Due for Telegram
Signature and Designation of Officer.
* Strike out what is inapplicable.
Printed and Published for the Government of the Commonwealth of Australia by J. Kemp, Government Printer for the State of Victoria.