H.—6b

2

Date, place, cause, and extent of disablement: Date and place of admission into hospital, and where and when discharged from hospital; amount and date of Government pension or gratuity, stating which : If assistance has already been given, state by which fund and to what extent: If married, state ages of wife and children, if any, and if earning anything. State if father, mother, or any other near relatives alive, and if able to assist applicant: Present means of existence, stating how applicant proposes to make a livelihood: Present address of applicant: Applicant's signature: Date of application: Signature and address of person verifying, who is requested to state shortly what he knows of applicant's character, habits, &o. T Approximate Cost of Paper.— Preparation, not given; printing (1,375 copies), £1 Os. 6a.

By Authority: John Mackay, Government Printer, Wellington.—l9oo.

Price 3d.]