S.I. No. 678/1935 - The Widows' and Orphans' Pensions (Claims and Payment Regulations) Order, 1935.

STATUTORY RULES AND ORDERS. 1935. No. 678.

THE WIDOWS' AND ORPHANS' PENSIONS (CLAIMS AND PAYMENT REGULATIONS) ORDER, 1935.

THE WIDOWS' AND ORPHANS' PENSIONS (CLAIMS AND PAYMENT REGULATIONS) ORDER, 1935, MADE BY THE MINISTER FOR LOCAL GOVERNMENT AND PUBLIC HEALTH WITH THE CONSENT OF THE MINISTER FOR POSTS AND TELEGRAPHS ON THE 27TH DAY OF DECEMBER, 1935, PURSUANT TO SECTION 65 of THE WIDOWS' AND ORPHANS' PENSIONS ACT, 1935 .

WHEREAS it is enacted by paragraph (a) of sub-section (1) of Section 65 of the Widows' and Orphans' Pensions Act, 1935 , that the Minister for Local Government and Public Health may by order make regulations for prescribing the manner in which claims to pensions may be made, and the manner in which pensions are to be paid :

AND WHEREAS it is enacted by paragraph (c) of sub-section (1) of Section 65 of the said Act that the Minister for Local Government and Public Health may by order make regulations for authorising in such cases as may be prescribed the payment of any sum by way of pension during any period intervening between the making of any claim or the referring of any question and the final determination of the claim or question :

AND WHEREAS it is enacted by paragraph (i) of sub-section (1) of Section 65 of the said Act that the Minister for Local Government and Public Health may by order make regulations for prescribing any matter or thing referred to in the said Act as prescribed or to be prescribed :

AND WHEREAS it is enacted by sub-section (2) of Section 65 of the said Act that regulations under the said Section for prescribing the manner in which pensions are to be paid shall be made with the consent of the Minister for Posts and Telegraphs :

NOW, THEREFORE, the Minister for Local Government and Public Health in exercise of the powers conferred on him by the said Section 65 of the Widows' and Orphans' Pensions Act, 1935 , and of every and any other power him in this behalf enabling, with the consent of the Minister for Posts and Telegraphs, hereby orders as follows, that is to say :—

1 Short Title.

1. This Order may be cited for all purposes as the Widows' and Orphans' Pensions (Claims and Payment Regulations) Order, 1935.

2 Interpretation.

2. The following regulations shall have effect for the purposes of the Widows' and Orphans' Pensions Act, 1935 , that is to say :—

(1) In these Regulations—

The expression " the Act " means the Widows' and Orphans' Pensions Act, 1935 .

The expression " the Minister " means the Minister for Local Government and Public Health.

The expression " widow's pension " means a pension which is either a widow's (contributory) pension or a widow's (non-contributory) pension.

The expression " orphan's pension " means a pension which is either an orphan's (contributory) pension or an orphan's (non-contributory) pension.

The expression " contributory pension " means a pension which is either a widow's (contributory) pension or an orphan's (contributory) pension.

The expression " child's allowance " means an allowa ce which is either a child's (contributory) allowance or a child's (non-contributory) allowance.

The word " pension " means any pension under the Act.

(2) The Interpretation Act, 1923 , applies to the interpretation of this Order and of the Regulations hereby made thereunder in like manner as it applies to the interpretation of an Act of the Oireachtas.

3 Manner of making claim.

3.—(1) Every person who desires to make a claim for a pension shall fill up a form of application for the pension and deliver or send the form when filled up to the Minister or to such officer or person as the Minister may appoint for the purpose.

(2) (a) The application shall be in the appropriate form set out in the Schedule to these Regulations, or in such other form substantially to the like effect as the Minister may determine: provided that—

where upon the death of a widow who had made application for and was entitled to a widow's pension as part of which a child's allowance was payable, any child in respect of whom such child's allowance was payable becomes eligible for an orphan's pension, the Minister may treat the application for the widow's pension as an application for an orphan's pension in respect of that child;

(b) where a claim for a pension is not duly signed or attested at the date of receipt by the Minister or such officer or person as the Minister may appoint for that purpose, the Minister may, provided that the claim is duly signed or attested and returned within one month of the date on which it is delivered to the applicant for completion, treat the claim as valid;

(c) where a claim for a pension has been made on a prescribed form other than the appropriate form, the Minister may treat the claim as if it had been made on the appropriate form and if in any particular case the Minister requires the claimant to complete the appropriate form, he may, if he thinks fit, treat the claim as made on the date on which a claim on the form other than the appropriate form was made.

(3) Every postmaster shall supply on demand a form of application, gratis, to any person who desires to make a claim for pension, except in the case of orphans' pensions, when the Minister shall cause the form to be supplied, gratis, to the person desiring to make the claim.

(4) Every person making a claim for a pension shall furnish such certificates by employers and others and such other documents and information as the Minister may require in connection therewith, and shall for that purpose attend at such office or place as the Minister may require.

4 Determination of Claim and Notice of Award.

4.—(1) A deciding officer appointed by the Minister under Section 49 of the Act may, in giving his award or decision on any claim made under these Regulations, have regard to any such evidence or information as in his opinion is sufficient for the purpose.

(2) The Minister shall cause due notice of the award or decision of a deciding officer on a claim to be given in writing to the person making the claim.

5 Pensions payable by pension orders through Post Offices.

5.—(1) Subject as hereinafter provided, pensions shall be paid through the Post Office by means of pension orders payable in each case to the person to whom the pension is payable under the Act (in this Article referred to as "the pensioner") at such post office as the Minister, after consultation with the pensioner, may from time to time determine, the post office at which the pension is payable in the particular case being in this Article referred to as "the appropriate post office."

(2) In every case in which there is an award or decision under which a pension is payable, the Minister shall cause arrangements to be made whereby, on furnishing such evidence of identity and such other particulars as may be required, the pensioner may obtain (either through the postmaster of the appropriate post office or otherwise) a book of pension orders, and the Minister shall cause to be sent to the pensioner written intimation of the appropriate post office and of the arrangements so far as affecting the pensioner.

(3) The pensioner shall furnish, in writing, a statement in such form as the Minister may require, and at such times as the Minister may determine, with respect to the pension continuing to be payable to him.

(4) The Minister shall cause arrangements to be made for the issue to every pensioner either by the postmaster at the appropriate post office or otherwise of a fresh book of pension orders on the expiration of the previous book.

(5) Notwithstanding anything in this Article the Minister may in any particular case arrange for the payment of the pension otherwise than by means of pension orders through the post office.

6 Prescribed day for payment of pensions

6. The prescribed day in the week for the purposes of the weekly payments on account of pension shall be Friday.

7 Delivery up of Pension Order Book on termination of Pension.

7. Upon the death of a person entitled to a pension any person having possession or thereafter obtaining possession of the pension order book, and on the marriage of a widow entitled to a widow's pension the widow, shall deliver to the Minister the pension order book then current.

8 Interim payments of pensions.

8. Where a claim for a pension has been duly made and the claim or any question in connection therewith has not been finally determined, the Minister may, if a deciding officer is satisfied that the claimant has furnished all such particulars in connection with the claim as she is in a position to furnish, and has produced all particulars and documents in connection therewith which are in her possession or the possession of which she would be able readily to secure, and that, subject to the production of further particulars or documents, the claim appears to be valid, authorise payment of a sum by way of pension for such period or periods as the Minister may from time to time determine.

9 Persons suffering from incapacity.

9.—(1) Where any person, being either a person to whom a pension is payable or a person who is alleged to be entitled to a pension or a person by whom or on whose behalf a claim has been made, is by reason of any mental or other incapacity unable to act and no committee or quasi-committee of her estate has been appointed, the Minister may, upon written application being made to him, appoint a person to exercise on behalf of the person unable to act any right to which that person may be entitled under the Act and to receive on behalf and for the benefit of that person any sums which may become payable to that person by way of a pension; provided that—

(a) no person under 18 years of age shall be capable of being appointed to act under this Article; and

(b) the Minister may at any time in his absolute discretion revoke any appointment made under this Article; and

(c) any person appointed under this Article may, on giving the Minister one month's notice of his intention so to do, resign his office.

(2) Anything required by these Regulations to be done by or to any such person as aforesaid who is by reason of any mental or other incapacity unable to act, may be done by or to the committee or quasi-committee of his estate, if any, or by or to the person appointed under this Article to act on his behalf.

10 Prescribed cases where pension payable in respect of late claims.

10. Where it is shown that failure to make a claim for a contributory pension within the time specified in sub-section (1) (e) (i) of Section 35 of the Act was due to circumstances over which the claimant had no control, the contributory pension shall commence to accrue on the date on which the claimant became entitled thereto in the following cases:—

(a) where the person in respect of whose insurance the contributory pension becomes payable died outside Saorstát Eireann;

(b) where the failure to make the claim within the time aforesaid was due to—

(i) the inability of the claimant to obtain the appropriate form of application from a postmaster; or

(ii) the person entitled to the pension being unable to act and to instruct any person to act on his behalf by reason of bodily or mental incapacity;

(c) where the person in respect of whose insurance the pension becomes payable disappeared more than one month prior to the date on which the claim is made and his death is presumed to have taken place on or about the date on which he disappeared.

11. Where a claim has been made in the prescribed manner the claim may be amended by notice in writing delivered or sent to the Minister or to such officer as the Minister may appoint for the purpose and the provisions of Section 35 of the Act shall apply to the amended claim as though it were a new claim.

12. Any notice or other document required or authorised to be sent to any person for the purpose of these Regulations shall be deemed to be duly sent if sent by post addressed to that person at his ordinary address.

By Order of the Minister for Local Government and Public Health.

Dated this 27th day of December, 1935.

SEÁN T. Ó CEALLAIGH,

Minister for Local Government and Public Health.

The Minister for Posts and Telegraphs hereby consents to the foregoing Order.

GERALD BOLAND.

SCHEDULE.

APPLICATION FOR WIDOW'S PENSION.

PART I.

1. Full name of claimant : Surname............................................................ ............................................................ ...

(in block capitals)

Christian name(s)............................................................ ........................

2. Full postal address............................................................ ............................................................ .........................

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

3. Full address of the Post Office at which you desire that pension (if awarded) should be paid............

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

Day of the Month

Month

Year

4. When were you born?

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

5. Are you sending your birth or baptismal certificate with this claim (Yes orNo)

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

(If not, you must fill in space 18.)

6. What was your husband's full name ?

Surname............................................................ .....................................

Christian name(s)............................................................ ......................

Day of the Month

Month

Year

7. When was your husband born?

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

8. Are you sending your husband's birth or baptismal certificate with this claim ?

(If not, you must fill in space 19.)

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

Day of the Month

Month

Year

9. When were you married to your husband?

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

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

10. Are you sending your marriage certificate with this claim ?

(If not you must complete space 20.)

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

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

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

11. State particulars of your husband's National Health insurance :—

(a) Name of his Society or Fund............................................................ .........................

(b) Name and number of Branch............................................................ ........................

(if any)

	Day of the Month	Month	Year
12. (a) State the date of your husband's death	.........................	........................	........................
(b) What was his home address at the date of his death ?	........................	........................	........................
13. Are you sending the certificate of your husband's death with this claim ?	........................	........................	........................
(If not, you must fill in space 21.)
14. What was your husband's usual occupation during the years before he died?	........................	........................	........................
15. Give, as far as possible, the periods of employment of your husband during the three years before he died.

Name and Address of Employer	Period in which he worked	Nature of Employment
From	To

16. Have you married since the death of your husband named at (6) above?	............................................................ ..............................
17. Are you at present in receipt of, or have you claimed—
(a) Home Assistance ?	............................................................ ............................
(b) Unemployment Assistance ?	............................................................ .............................

18. PARTICULARS OF CLAIMANT'S BIRTH.

This space need not be filled in if a birth certificate is sent with the claim.

Date of birth............................................................ ............................................................ .............................................

Place where born (Street or Road)............................................................ ............................................................ ........

Town or Paris and County............................................................ ............................................................ .....................

Father's full name and surname............................................................ ............................................................ ............

Father's occupation............................................................ ............................................................ ...............................

Mother's full name and surname............................................................ ............................................................ ........

Mother's maiden surname............................................................ ......... ............................................................ ........

19. PARTICULARS OF BIRTH OF HUSBAND OF CLAIMANT.

Date of birth............................................................ ............................................................ .......................................

Place where born (Street or Road)............................................................ ............................................................ .

Town or Paris and County............................................................ ............................................................ .............

Father's full name and surname............................................................ ............................................................ .....

Father's occupation............................................................ ............................................................ ........................

Mother's full name and surname............................................................ ............................................................ ..

Mother's maiden surname............................................................ ............................................................ ............

This space need not be filled in if a birth certificate is sent with the claim.

20. PARTICULARS OF CLAIMANT'S MARRIAGE.

Date of Marriage............................................................ ............................................................ ...................................

Place of Marriage (Town or Village and County)............................................................ ........................................

Name and Religious Denomination of Church or name of Registry Office..........................................................

What was your name before marriage ?............................................................ ........................................................

This space need not be filled in if a certificate of marriage is sent with the claim.

21. PARTICULARS OF HUSBAND'S DEATH.

Date of your husband's death............................................................ ............................................................ ..........

Place of death (full address)............................................................ ............................................................ .............

His age when he died............................................................ ............... ............................................................ ........

This space need not be filled in if a certificate of death is sent in with the claim.

22. PARTICULARS OF LIVING CHILDREN OF THE CLAIMANT AND/OR HER HUSBAND, WHO ARE UNDER 14 YEARS OF AGE

Child's full Christian Name(s) and Surname	Date of Child's Birth Day, Month, Year	Place where child was born Street or Road and Town (or Townland in Rural Area) or Parish and County	Father's full Christian Name(s) and Surname	Father's Occupation	Mother's full Christian Name(s) and Surname	Mother's Maiden Name

PARTICULARS OF LIVING CHILDREN OF THE CLAIMANT AND/OR HER HUSBAND, WHO ARE OVER THE AGE OF 14 AND UNDER THE AGE OF 16, AND ARE EITHER UNDER FULL-TIME INSTRUCTION IN A DAY SCHOOL, OR ARE PHYSICALLY OR MENTALLY INCAPACITATED FROM ATTENDING SCHOOL OR EARNING A LIVELIHOOD.

Child's full Christian name(s) and Surname	Date of Child's Birth Day Month Year	Whether Child is attending School or is in-capacitated	Place where Child was born, Street or Road, Town or Parish and County	Father's Full Christian Name(s) and Surname	Father's Occupation	Mother's Full Christian Name(s) and Surname	Mother's Maiden Name

23. (a) Give particulars of the addresses at which you lived during the past two years	............................................................ ...........................
(b) Give particulars of the addresses at which your husband lived during the two years immediately before the date of his death	............................................................ ...........................
24. State the annual income of yourself and any children in respect of whom children's allowances are being claimed.	............................................................ ...........................
(The attached Form on pages 10 and 11 must be completed in detail.)

PART II

This part of the Form must also be completed by a widow of a smallholder who claims a widow's (non-contributory) pension.

25. Was your husband the occupier of a holding or holdings of agricultural land at the time of his death? If so, give particulars and state the valuation of each holding
	Where situated	Valuation
	................................. ................................. ................................	............................... ............................... ...............................
26. Was your husband at the time of his death the occupier or owner of any other rateable property (for example, land, houses, buildings, etc.) not included in the reply to Question 25 ? (If so, give particulars and state in each case, the valuation.)
27. Are you at present resident on the holding or any of the holdings referred to in question 25 ?
	............................................................ ......................

28. I HEREBY apply for a Widow's Pension, and such Children's Allowances as I am entitled to under the Widows' and Orphans' Pensions Act, 1935 . I declare that I am the widow of the man named in the reply to question 6 of this Form, and that all the children named on page 5 of this Form are living and are my own and/or my husband's, or of a former wife of my husband, and that there are no other living children, either my own or my husband's or of any former wife of my husband, within the specified ages.

I declare that to the best of my knowledge and belief all the information which I have given in this application is true. I declare that I am not disqualified, nor are any of the children named on page 5 disqualified by reason of any of the Disqualifications stated below which I have read.

Claimant's Signature (or Mark if unable to write).*

...........................................................Date................................................ 193...

The claimant must sign or mark the claim herself unless she is incapable of so doing through bodily or mental infirmity. In such a case any person claiming to act on her behalf should communicate with the Controller, Department of Local Government and Public Health, Widows' and Orphans' Pensions D'Olier House, D'Olier Street, Dublin.

*The signature should be the applicant's usual signature and the christian names should be the applicant's, not her late husband's.

29. PERSON QUALIFIED TO CERTIFY.	THIS PART OF THE FORM MUST BE SIGNED BY A PERSON HAVING ONE OF THE QUALIFICATIONS SHOWN IN THE MARGIN.
The signature of a relative of the claimant cannot be accepted.
1. A Peace Commissioner.	I (name).................................................
2. A Barrister or Solicitor.
	of (address)..........................................
3. A Minister of Religion (stating Denomination and address of place of worship).	............................................................ ........
4. A Medical Practitioner.
	(qualification).................................
5. A Member of the Oireachtas.
6. A Head Teacher of a Public Elementary or Secondary School, or a recognised teacher at a University (stating name and address of the school or University).	certify that the claimant is known to me personally; that all the statements in this claim are true to the best of my knowledge and belief. The signature (or mark) above was made or acknowledged by the claimant this day in my presence.
7. *A member of the Gárda Síothchána not below the rank of Sergeant.
	Signature of Certifier	}	............................................................ ..........
8. *The Clerk or any Member of a Local Authority.
9. *A Relieving Officer.	Date...............................................

* If an official stamp denoting the office is in use it should be impressed on the certificate.

DISQUALIFICATIONS.

A widow is by law disqualified from receiving a pension in the following cases:—

(1) If, and so long as she and any person are cohabiting together as man and wife.

(2) While she is in prison under a sentence of imprisonment without the option of a fine, or under sentence of penal servitude.

(3) While she is being maintained in any place as a criminal lunatic, or as a non-paying patient in any district or auxiliary mental hospital.

A child's (non-contributory) allowance is not payable if condition (1) is applicable or if the child is resident outside Saorstát Eireann.

Allowances in respect of children are not payable if either condition (2) or (3) is applicable, the child being then treated as an orphan for pension purposes.

A child's allowance cannot be claimed by a widow in respect of a child who has been removed from her custody by order of a Court, sent to a reformatory or industrial school, deserted or abandoned, or who is an inmate of an institution or boarded out by a local authority. In such cases the child is treated as an orphan for pension purposes.

TO BE FILLED IN ONLY WHEN THE CLAIMANT HAS BEEN ASSISTED BY A SUB-POSTMASTER.

I have assisted the claimant to fill up this form.

DATE

STAMP

Signature............................................................ ..............................

Sub-Postmaster of...........................

I certify that the applicant assisted in this case has been granted a pension

(No..........................) Signature............................................................ ...............................................

Deciding Officer.

Date.................................... 193......

I CERTIFY that the undermentioned child(ren) is/are living and has/have been seen by me this day and that the child(ren) over 14 is/are under full-time instruction in a Day School.

Certificates must be obtained from the Head Teacher of each School which any of the children named hereon is attending.	*Full Name of Child	*Full Address at which Child is now Living	Name and Address of School	Signature of Head Teacher of School	Date


If on account of school holidays the Head Teacher's Certificate cannot be obtained, the claim should not be delayed, but the circumstances should be explained.

*Name and present address of child(ren) to be inserted by claimant.

STATEMENT AS TO ANNUAL MEANS TO BE COMPLETED BY CLAIMANTS FOR NON-CONTRIBUTORY PENSIONS.

1. Have you a farm, a business, or any house or other property or have you any right in any property ?	............................................................ ............................
(a) If so, state where it is situated	............................................................ ............................
(b) Describe it, giving such particulars as Poor Law Valuation, Rent, Turnover, etc.	............................................................ ............................
	............................................................ ............................
2. (a) Do you pay rent for the house or lodging in which you reside, or do you own it ?	............................................................ ............................
(b) If you pay rent, particulars stating whether it is payable under a lease or a yearly or shorter tenancy should be given	............................................................ ............................
3. Have you money in hand, at Bank, loaned, or invested ? If so, state amount	............................................................ ............................
4. State the net cash value of any income derived during the past twelve months from your own personal exertions	............................................................ ............................
5. State the total moneys received by you during the past twelve months by way of sickness or disablement benefit under the National Health Insurance Acts or from a friendly society or a trade union or by way of Unemployment Benefit under the Unemployment Insurance Acts (moneys received in respect of your late husband should not be included)	............................................................ ............................
6. State the sources and the total value of all income you may reasonably expect to receive during the coming year in cash, including any money that you may receive as head of the household from members of the household or others by way of contribution to household expenses, but excluding any that may come in under headings in questions 4 and 5	............................................................ ............................
7. Have you had, in the last twelve months, any property or income which you do not own or receive at present ? If so, give particulars and state what has become of it ?	............................................................ ............................
8. Are you in receipt of a blind pension ?	............................................................ ............................

I have clearly understood the above questions, and to the best of my knowledge and belief all the statements made by me are correct.

Signature or Mark of Claimant............................................................ .................

Date............................................................ ........

Signed (or mark made) in my presence :

Witness............................................................ ..............................................

Address............................................................ .............................................

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

The claimant must write her signature in this space in addition to signing the declaration above.

APPLICATION FOR ORPHAN'S PENSION.

PART 1.

PARTICULARS OF APPLICANT (THAT IS, THE GUARDIAN OR PERSON HAVING CHARGE OF THE ORPHAN).

(1) Full name of applicant : Surname............................................................ .....................................................

(in block capitals)

Christian name(s)............................................................ .......................................

(2) Full postal address............................................................ ............................................................ ..............................

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

(3) Full address of the Post Office at which you desire that pension (if awarded) should be paid....................

PART 2.

PARTICULARS OF EACH LIVING CHILD UNDER 14 YEARS OF AGE FOR WHOM AN ORPHAN'S PENSION IS CLAIMED.

Child's Full Christian Name(s) and Surname	Date of Child's Birth : Day, Month, Year	Place where Child was born, Street or Road, Town (or Townland in Rural Area) or Parish and County	State where Child is now living

PARTICULARS OF EACH LIVING CHILD FOR WHOM AN ORPHAN'S PENSION IS CLAIMED WHO IS OVER THE AGE OF 14 AND UNDER THE AGE OF 16, AND IS EITHER UNDER FULL-TIME INSTRUCTION IN A DAY-SCHOOL, OR IS PHYSICALLY OR MENTALLY INCAPACITATED FROM ATTENDING SCHOOL OR ENGAGING IN ANY REMUNERATIVE OCCUPATION.

Child's Full Christian Name(s) and Surname	Date of Child's Birth : Day, Month, Year	Is Child attending School ?	Is Child incapacitated ?	Place where Child was born, Street or Road, Town (or Townland in Rural Area) or Parish and County	State where Child is now living

PART 3.

PARTICULARS OF DECEASED PARENTS OF CHILD(REN) NAMED IN PART 2.

(a) Full Name of Father and Mother		Date of Marriage			Date of Death
Surname	Christian Names	Day	Month	Year	Day	Month	Year
(Father)



(Mother)

(b) Are you sending the marriage certificate of the above-named parents with this claim ?	............................................................ .........................
If not, state :—
(i) Place of marriage (Town or Village and County)	............................................................ .........................
(ii) Name and Religious Denomination of Church or name of Registry Office	............................................................ .........................
(iii) The Mother's name before marriage	............................................................ .........................
(c) Are you sending the certificate of the Father's death with this claim ?	............................................................ .........................
If not, state :—
(i) The full address of the place of his death	............................................................ .........................
(ii) His age when he died	............................................................ .........................
(d) State the home address of the Father at the time of his death	............................................................ .........................
(e) What was his usual occupation during the 3 years before the date of his death ?	............................................................ .........................
(f) State particulars of his National Health Insurance (if known) :—
(i) Name of his Society or Fund	............................................................ ........................
(ii) Name and Number of Branch (if any)	............................................................ ........................
(iii) His membership number	............................................................ .......................
(These particulars can be obtained from his Contribution Card or Record Card.)
(g) Give, as far as possible, the periods of his employment during the three years before he died :

Name and Address of Employer	Period in which he worked	Nature of employment
From	To

(h) Are you sending the certificate of the Mother's death with this claim ?	............................................................ ..............................
If not, state :—
(i) The full address of the place of her death	............................................................ ..............................
(ii) Her age when she died	............................................................ ..............................
(i) State the home address of the Mother at the time of her death	............................................................ ..............................
(j) What was her usual occupation during the 3 years before the date of her death ?	............................................................ ..............................
(k) State particulars of her National Health Insurance (if known) :—
(i) Name of her Society	............................................................ ..............................
(ii) Name and Number of Branch (if any)	............................................................ ..............................
(iii) Her membership number	............................................................ ..............................
(These particulars can be obtained from her Contribution Card or Record Card.)
(l) Give, as far as possible, the periods of her employment during the 3 years before she died :

Name and Address of Employer	Period in which she worked	Nature of employment
From	To

(m) Give particulars of the addresses at which the children named in Part 2 have lived during the past twelve months	............................................................ .............................
(n) State the Annual income of those children	............................................................ .............................
(The Form on page 8 must be completed in detail.)

PART 4.

This part of the Form together with Parts 1 to 3 must be completed by the applicant for an orphan's (non-contributory) pension in respect of the child of a smallholder.

(a) (i) Was either parent the occupier of a holding or holdings of agricultural land at the time of his or her death ?	............................................................ ...........................
(ii) If so, which parent (father or mother) ?	............................................................ ............................
	WHERE SITUATED	VALUATION
(iii) Give particulars of the holding or holdings and state valuation of each	.........................................	.........................................
(b) Was the parent referred to in (a) (ii) at the time of his or her death the occupier or owner of any rateable property (for example, land, houses, buildings, etc.) not included in reply to above questions ? If so, give particulars and in each case the valuation	.........................................	..........................................
	.........................................	.........................................
.........................................	.........................................

PART 5.

I CERTIFY that the undermentioned Child(ren) is/are living and has/have been seen by me this day and that the Child(ren) over 14 is/are under full-time Instruction in a Day School.

* Full Name of Child	* Full Address at which Child is now living	Name and Address of School	Signature of Head Teacher of School	Date





Certificates must be obtained from the Head Teacher of each School which any of the children named hereon is attending.		If on account of school holidays the Head Teacher's Certificate cannot be obtained, the claim should not be delayed, but the circumstances should be explained.

* Name and present address of child(ren) to be inserted by applicant.

PART 6.

Is any other Pension or Allowance under the Widows' and orphans' Pensions Act being paid, or claimed, for the benefit of any of the children named in Part 2 of this Form ?

}

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

PART 7.

CERTIFIED APPLICATION FOR AN ORPHAN'S PENSION.

This application and Declaration must be Signed and Dated by the Applicant in the Presence of the Person who Signs Part 8 below.

I hereby apply for an Orphan's Pension under the Widows' and Orphans' Pensions Act, 1935 , in respect of the child(ren) named in Part 2 of this Form. I declare that I am the /images/v22p0481a.gif of the child(ren) and that /images/v22p0481b.gif the child(ren) of ............................................................ ...... and ............................................................ ..., both of whom are dead. I declare that to the best of my knowledge and belief all the information which I have given in this application is true.

* Delete as necessary.

* Signature (or Mark, if unable to write) ............................................................ ...............

* The signature should be the applicant's usual signature

Date .........................................................

PART 8.

THIS CERTIFICATE MUST BE SIGNED AND DATED IN THE PRESENCE OF THE APPLICANT. THE PERSON SIGNING THIS PART OF THE FORM MUST POSSESS ONE OF THE QUALIFICATIONS SHOWN IN THE MARGIN AND MUST SO DESCRIBE HIMSELF IN THE SPACE PROVIDED UNDER HIS SIGNATURE.

Person qualified to Certify.	I certify that the applicant is known to me personally, that the particulars stated in the above application are true to the best of my knowledge and belief, and that the signature (or mark) in Part 7 was made or acknowledged in my presence,this day by the applicant, and I certify that the child(ren) whose name(s) and date(s) of birth are stated in Part 2 of this form is/are living at this date and is/are to the best of my knowledge and belief the child(ren) of the late
1. A Peace Commissioner.
2. A Barrister or Solicitor.
3. A Minister of Religion (stating Denomination and address of place of Worship).
4. A Medical Practitioner.
5. A Member of the Oireachtas.
6. A Head Teacher of a Public Elementary or Secondary School, or a recognised Teacher at a University (stating name and address of the School or University).	............................................................ .............................
	and ............................................................ .....................
Signature,............................................................ ..........
	Date......................................................193...............

*p0483ast7. A Member of the Garda Siothchana not below the rank of Sergeant.	Full Address............................................................ .....
*p0483ast8. The Clerk or any Member of a Local Authority.	............................................................ ............................
*p0483ast9. A Home Assistance Officer.	............................................................ ............................
	Qualification (See margin)...........................................

If an official stamp denoting the Office is in use it should be impressed on the Certificate.

STATEMENT AS TO ANNUAL MEANS TO BE COMPLETED IN RESPECT OF EACH CHILD FOR WHOM AN ORPHAN'S (NON-CONTRIBUTORY) PENSION IS CLAIMED. A SEPARATE ANSWER MUST BE GIVEN TO EACH QUESTION IN RESPECT OF EACH CHILD, THE NAME OF THE CHILD BEING STATED IN EACH CASE.

1. Has he a farm, a business, or any house or other property, or has he any right in any property ?	............................................................ ............................
(a) If so, state where it is situated.	............................................................ ...........................
(b) Describe it, giving such particulars as Poor Law Valuation, Rent, Turnover, etc.	............................................................ ...........................
2. (a) Does he pay rent for the house or lodging in which he resides, or does he own it ?	............................................................ ............................
(b) If he pays rent, particulars stating whether it is payable under a lease or a yearly or shorter tenancy should be given.	............................................................ ............................
3. Has he money in hand, at Bank, loaned or invested ? If so, state amount.	............................................................ ..............................
4. State the net cash value of any income derived during the past twelve months from his own personal exertions.	............................................................ .............................
5. State the sources and the total value of all the income he may reasonably expect to receive during the coming year in cash, but excluding any that may come in under headings in Question 4	............................................................ .............................

6. Has he had, in the last twelve months, any property or income which he does not own or receive at present? If so, give particulars and state what has become of it

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

I have clearly understood the above questions, and to the best of my knowledge and belief all the statements made by me are correct.

Signature or Mark of Applicant............................................................ .......................................

Date............................................................ .............................................

The Applicant must write his or her signature in this space in addition to signing the above declaration.

SIGNATURE