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STATUTORY RULES AND ORDERS. 1927. No. 74.
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ARMY PENSIONS (FORMS OF APPLICATION) REGULATIONS (No. 1), 1927.
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WHEREAS it is enacted by sub-section (1) of
section 27
of the
Army Pensions Act, 1927
(No. 12 of 1927) that the Minister for Defence may by order make regulations in regard to any matter or thing referred to in that Act as prescribed or as being or to be prescribed by regulations made under that Act :
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AND WHEREAS it is enacted by section 17 of the said
Army Pensions Act, 1927
, that every application for the grant of a pension, gratuity or allowance under the
Army Pensions Act, 1923
(No. 26 of 1923) as amended by the said
Army Pensions Act, 1927
, or under the said
Army Pensions Act, 1927
, shall be made to the Minister for Defence in the prescribed form and shall contain the prescribed particulars :
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AND WHEREAS it is enacted by
section 11
of the
Ministers and Secretaries Act, 1924
(No. 16 of 1924) that it shall be lawful for any Minister pursuant to any arrangement or agreement previously authorised by an Order of the Executive Council to exercise and perform any of the duties or public services of any other Minister as agent for such Minister and without relieving such other Minister of his responsibility for the administration of such public service :
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AND WHEREAS by an Order entitled the Minister for Defence (Agency) Order, 1927, dated the 24th day of June, 1927, made by the Executive Council in pursuance of the said section 11 of the said
Ministers and Secretaries Act, 1924
, the President is authorised to exercise and perform as agent for the Minister for Defence any of the duties and public services of the Minister for Defence during the inability of that Minister through ill-health to exercise and perform such duties and public services :
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NOW, I, LIAM T. MACCOSGAIR, President of the Executive Council, in exercise of the powers conferred on the Minister for Defence by the
Army Pensions Act, 1927
(No. 12 of 1927), and of the powers conferred on me by the Minister for Defence (Agency) Order, 1927, made by the Executive Council in pursuance of
section 11
of the
Ministers and Secretaries Act, 1924
(No. 16 of 1924), and of every and any other power me in this behalf enabling do hereby make the following regulations :—
1.—This Order may be cited as the Army Pensions (Forms of Application) Regulations Order, 1927.
2.—In this Order—
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the expression " the Principal Act " means the
Army Pensions Act, 1923
(No. 26 of 1923) and
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the expression " the Act of 1927 " means the
Army Pensions Act, 1927
(No. 12 of 1927).
3.—The
Interpretation Act, 1923
(No. 46 of 1923) applies to the interpretation of this Order in like manner as it applies to the interpretation of an Act of the Oireachtas.
4.—(1) Every application under sections 9, 10 or 13 of the Act of 1927 for the grant of a disability pension shall be in the Form No. A.P. 28 in the Schedule hereto and shall contain the particulars asked for or otherwise indicated in that Form.
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(2) Every application under section 14 of the Act of 1927 for the grant of an allowance or gratuity in respect of the death of a person shall
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(a) if made by the widow of the deceased person on behalf of herself or on behalf of herself and the deceased person's children, be in the Form No. A.P.29 in the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form, and
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(b) if made on behalf of the children of the deceased person by a person other than the widow of the deceased person, be in the Form No. A.P.30 in the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form.
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(3) Every application under section 14 of the Act of 1927 for the grant of a gratuity in respect of the death of a person made by or on behalf of a dependant (not being the widow or child) of the deceased person shall be in the said Form No. A.P.30 in the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form.
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(4) Every application under section 1 of the Principal Act as amended by the Act of 1927 or under section 11 of the Act of 1927 for the grant of a wound pension shall be in the Form No. A.P.31 in the Schedule hereto and shall contain the particulars asked for or otherwise indicated in that Form.
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(5) Every application under sub-section (1) of section 15 of the Act of 1927 for the grant of an allowance or gratuity in respect of the death of a person shall—
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(a) if made by the widow of the deceased person on behalf of herself or on behalf of herself and the deceased person's children, be in the Form No. A.P.32 in the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form, and
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(b) if made on behalf of the children of the deceased person by a person other than the widow of the deceased person, be in the Form No. A.P.33 in the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form, and
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(c) if made on behalf of a dependant (not being the widow or a child) of the deceased person, be in the said Form No. A.P.33 of the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form.
6.—Every application under section 12 of the Act of 1927 for the grant of a wound pension shall be in the Form No. A.P.34 in the Schedule hereto and contain the particulars asked for or otherwise indicated in that Form.
7.—Every application under sub-section (2) of section 15 of the Act of 1927 for the grant of an allowance or gratuity shall be in the Form No. A.P.35 in the Schedule hereto and shall contain the particulars asked for or otherwise indicated in that Form.
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Made and prescribed in exercise of the powers aforesaid this tenth day of August, 1927.
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LIAM T. MACCOSGAIR,
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Aire Cosanta Gníomhathach.
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(SECOND AND THIRD SCHEDULES.)
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A.P. 28.
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ARMY PENSIONS ACTS, 1923 AND 1927.
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DISABILITY PENSION.
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APPLICATION BY A PERSON CLAIMING A DISABILITY PENSION UNDER
SECTIONS 9
,
10
OR
13
OF THE
ARMY PENSIONS ACT, 1927
.
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The questions are to be answered in the claimant's own words, and the form is to be signed by him and the signature witnessed. In the event of the claimant being unable to write he should affix his mark, such act being witnessed.
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Army No......................................
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Rank............................................................ ..............................................
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Unit and Corps
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............................................................ ............................................................ .......................
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Name and Rank of Commanding Officer............................................................ ...............................................
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............................................................ ............................................................ .........................................................
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Name (To be written in block capitals)
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............................................................ ..........................................
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(Surname)
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(Christian Names)
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Rank in
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Irish Volunteers
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............................................................ .....................................................
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Irish Citizen Army, 1916
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............................................................ ..........................................
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National Army
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............................................................ ......................................................
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Age last birthday
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............................................................ ............................................................ ................
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Present Address
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............................................................ ............................................................ ......................
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Nearest Gárda Síochána Station
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............................................................ ......................................................
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Note.—Before answering the questions below, the applicant is to note that :
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(a) The statement made by him will be checked from official records. Section 12 (1) of the Act imposes a summary penalty for a false declaration:—" Every person who, with a view to obtaining the grant or payment of a pension, allowance, or gratuity under this Act, either for himself or for any other person, makes, signs, or uses any declaration, application, or other written statement knowing the same to be false, shall be guilty of an offence under this section, and shall be liable on summary conviction thereof to a fine not exceeding twenty-five pounds or, at the discretion of the court, to imprisonment for any term not exceeding six months, or to both such fine and such imprisonment."
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(b) In answering question 3 any special circumstances involved in his service which, in claimant's opinion, caused any unfitness from which he may be suffering should be clearly stated.
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If the applicant is unable to read, the above notes should be read over to him by the witness, who should so testify in his attestation of the claim.
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1. State for what period you served in:
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Irish Volunteers
Irish Citizen Army
National Army
Defence Forces
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(a) In what capacity, and in what area or areas?
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(b) Who was your Commanding Officer, or Officers, in the several Forces?
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(c) If you served in the National Army or Defence Forces, state the date upon which you were discharged from the Army or Forces
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2. What is the disability (or disabilities) for which you now claim a pension?
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3. In what way do you claim that your disability is connected with your Military Service, and what grounds have you for the claim? (A detailed statement of the facts, with dates, should be given.)
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4. (a) When, and in what district, did the disability (or disabilities) commence?
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(b) Who was your Commanding Officer at the time?
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(c) Give the names of any persons who can corroborate your answer to (a) above.
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5. Were there any particular conditions affecting your service which you claim caused the disability (or disabilities)?
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6. Give particulars of your health for the three years prior to joining the particular Force in which you claim to have incurred the disability (or disabilities). If possible, certificates should be furnished.
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(a) From your doctor; and
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(b) From your Approved Society for the three years prior to joining the particular Force, or if you were not an insured person, certificates should be furnished by the Medical Practitioner who ordinarily attended you during those three years. A statement will also be required from your Employer or Employers in respect of the three years prior to your joining the particular Force.
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7. Give the names of the Hospitals where you have been treated for the disability (or disabilities) stated in reply to question 2 above, and the approximate dates of admissions and discharges
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8. Did you suffer from the disability (or disabilities) mentioned in above answer to Question 2, or anything like it, prior to your service as stated in reply to Question 1? If so, give details and dates
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9. Give the names of any hospital, or hospitals, in which you received treatment as an in-patient or an out-patient, prior to the period of your service, and the nature of the ailment for which treatment was provided
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10. What was the nature of your employment
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(a) Before joining the Irish Volunteers, Irish Citizen Army, or National Army?
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(b) During the period of your service with the Irish Volunteers or Irish Citizen Army?
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(c) After the cessation of your Military Service?
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11. Give the names and addresses of your Employer, or Employers:
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(a) During the three years prior to joining the particular Military Force in which you claim to have contracted the disability (or disabilities) referred to in the reply to Question 2 above
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(b) During the period of your service with the Irish Volunteers or Irish Citizen Army
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(c) During the period since the cessation of your Military Service.
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12. Were you at any time prior to joining the Forces a candidate for any appointment which necessitated a medical examination? If so, state the nature of the appointment, and the result of the medical examination
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13. Give particulars of any period, or periods, of unemployment since the cessation of your Military Service, and the cause of it (e.g., trade depression, ill-health, etc.)
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14. Have you received compensation from your employer, or from any person or body in respect of any accident, injury, or disease; and, if so, give full particulars and state the amount of such compensation
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15. Give the names and addresses of any doctors who attended you since the cessation of your Military Service
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16. If you have been treated at a hospital (either as an in-patient or an out-patient) since the cessation of your Military Service, give the name of the hospital or hospitals, dates of admission, or commencement of treatment, and the nature of the disease for which treated.
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17. Give particulars of your health since the cessation of your Military Service. These should be supported by :
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(a) Medical certificates from any civilian doctors who have attended you and reports from non-Military hospitals you have attended
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(b) Certificates from your employers as to health and time lost
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18. Have you received, in respect of the disability (or disabilities) mentioned in answer to Question 2 above, any payment :
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(a) On a decree under the Criminal Injuries (Ireland) Acts, 1919 and 1920
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(b) On an award made by the Personal Injuries Committee
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(c) From any relief organisation, such as National Aid or White Cross Association? If so, give full particulars
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19. Give the name of your National Health Approved Society, and (if possible) your Membership Number
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20. Have you at any time since the cessation of your Military Service been registered at a Labour Exchange? If so, give particulars as to the name of the Exchange and the period
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21. Is there any other information which you can give, which is material to your claim?
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22. Did you make a claim for a certificate of Service under the
Military Service Pensions Act, 1924
? If so, what was the result of your claim?
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23. Give particulars of any pension or gratuity awarded to you under the
Army Pensions Act, 1923
, in respect of a wound or injury received in the course of duty with the Irish Volunteers, Irish Citizen Army, 1916, or National Army
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24. Have you served at any period with any of the following Military or Police Forces? If so, give particulars of service:
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(a) British.
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(b) Australian.
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(c) New Zealand
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(d) South African.
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(e) Canadian
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( f ) American (U.S.A.)
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(g) Royal Irish Constabulary
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(h) Dublin Metropolitan Police
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(i) Gárda Síochána
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25. (a) Give full particulars of any pension, allowance or gratuity which you hold, or at any time have held in respect of any wound or injury received in or disease contracted in the services mentioned in your reply to above question
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(b) State clearly the source from which payment of such pension allowance or gratuity is made or has been made
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This statement has been read over to me ; it is my own statement, and is correct and complete. I have nothing to add to it.
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(Signed)............................................................ ...
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Address............................................................ ...
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(Ex-Officer or Ex-Soldier.)
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(Signed*)............................................................ .
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Address............................................................ ...
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(Witness.)
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Qualification........................................................
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Date............................................................ ........
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* To be signed by one of the following:—
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A Commissioned Officer serving in the Defence Forces.
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A Permanent Civil Servant (active or retired) whose salary is or was not less than £200 and on a scale rising to not less than £300.
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A District Justice.
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A Peace Commissioner.
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A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
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A Minister of Religion (denomination to be stated).
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A registered Physician or Surgeon.
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Managers, Secretaries, Chief Cashiers and Accountants of Banks, and Officials in charge of Branch Banks.
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A member of the Gárda Síochána.
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A Postmaster or Postmistress in actual charge of a Post Office.
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Head Teachers of Secondary or National Schools.
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A Secretary of a Registered Friendly Society.
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ARMY PENSIONS ACTS, 1923 AND 1927.
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Statement by a person who claims as a married man a further pension in accordance with the terms of the Acts.
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26. If your wife is alive:
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(a) State the date of your marriage
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(b) Is your wife dependent on you?
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(c) Does she ordinarily reside with you?
(Certificate of marriage to be attached.)
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27. (a) If your wife is dead, or the marriage has been dissolved, state the names and ages of any (To be filled in by ex-Officers) :
Sons under 18 years of age
Daughters under 21 years of age (To be filled in by ex-Soldiers) : Sons under 16 years of age
Daughters under 18 years of age (Certificates of birth of living children to be attached.)
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(b) State whether the child or children mentioned above are dependent on you, and where they are living
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(c) State whether any of the above children are married
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28. If your wife is alive, but your marriage has been dissolved, and you claim a further pension in respect of the children mentioned in the reply to Question 27 (a) above, please furnish copy of the decree or Order of the Court.
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The above statement has been read over to me; I agree to it, and have nothing further to add.
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(Signed............................................................ ........
|
Address............................................................ ............
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(Ex-Officer or Ex-Soldier.)
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(Signed*) ............................................................ ...
|
Address............................................................ ............
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(Witness.)
|
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Qualification ..........................................................
|
Date............................................................ ....................
|
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* To be signed by one of the following.—
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A Commissioned Officer serving in the Defence Forces.
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A Permanent Civil Servant (active or retired) whose salary is or was not less than £200 and on a scale rising to not less than £300.
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A District Justice.
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A Peace Commissioner.
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A Barrister-at-Law, a Solicitor, or a Commissioner for Oaths.
|
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A Minister of Religion (denomination to be stated).
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A Registered Physician or Surgeon.
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Managers, Secretaries, Chief Cashiers and Accountants of Banks, and Officials in charge of Branch Banks.
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A member of the Gárda Síochána.
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A Postmaster or Postmistress in actual charge of a Post Office.
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Head Teachers of Secondary or National Schools.
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A Secretary of a Registered Friendly Society.
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(SIXTH AND SEVENTH SCHEDULES.)
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A.P. 29.
|
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ARMY PENSIONS ACTS, 1923 AND 1927.
|
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APPLICATION BY A WIDOW FOR AN ALLOWANCE OR GRATUITY FOR HERSELF OR FOR HERSELF AND CHILDREN UNDER
SECTION 14
of THE
ARMY PENSIONS ACT, 1927
.
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NOTE.—This form is to be filled in by the applicant in person in her own words, and the form is to be signed by her and the signature witnessed. In the event of the applicant being unable to write, she should affix her mark, such act being witnessed.
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Name of Applicant (To be written in block capitals)............................................................ .........................
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(Surname)
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(Christian Name.)
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Address
|
............................................................ ............................................................ ...................................
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Nearest Gárda Síochána Station
|
............................................................ .....................................................
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Name of Deceased Member
|
............................................................ ...........................................................
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Rank in
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Irish Volunteers
|
............................................................ .....................................................
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Irish Citizen Army, 1916
|
............................................................ ........................................
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National Army
|
............................................................ .....................................................
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Unit............................................................ .......................
|
Army No............................................................ .
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Name and Rank of Commanding Officer............................................................ ..............................................
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............................................................ ............................................................ ........................................................
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NOTE.—Before answering any of the questions below, the applicant is to note that the statements made will be checked from official records.
|
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Section 12 (1) of the Act imposes a summary penalty for a false declaration :
|
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" Every person who, with a view to obtaining the grant or payment of a pension, allowance, or gratuity under this Act, either for himself or for any other person, makes, signs, or uses any declaration, application, or other written statement knowing the same to be false shall be guilty of an offence under this Section, and shall be liable on summary conviction thereof to a fine not exceeding twenty-five pounds or, at the discretion of the court, to imprisonment for any term not exceeding six months, or to both such fine and such imprisonment."
|
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If the applicant is unable to read, the above notes should be read over to her by the witness, who should so testify in his attestation of the claim.
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1. Give the date of marriage to the Deceased (Certificate of marriage to be attached)
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2. When and where did the Deceased die, and what was the cause or causes of death? (Certificate of death to be attached)
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3. In what way do you claim that the disability (or disabilities), which was the cause of death, was connected with the Military Service of the Deceased? What grounds have you for the claim? (A detailed statement of the facts, with dates, should be given)
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4. State for what period Deceased served in :
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Irish Volunteers
|
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|
Irish Citizen Army
|
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National Army, Defence Forces
|
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|
(a) When, and in what area or areas, did the disability (or disabilities) which resulted in death commence?
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(b) Who was the Deceased's Commanding Officer or Officers in the several Forces?
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(c) Give the names of any persons who can corroborate your answer to (a) above
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(d) If the Deceased served in the National Army or Defence Forces, state the date of discharge from the Army or Forces
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5. Were there any particular conditions affecting the Service of the Deceased which you claim caused the disability (or disabilities)?
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6. Give particulars of the health of the Deceased for the three years prior to joining the particular Force in which it is claimed he incurred the disability (or disabilities) which caused his death. If possible, certificates should be furnished :
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|
(a) From his Doctor ; and
|
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|
(b) From his Approved Society for the three years prior to his joining the particular Force, or, if he was not an insured person, certificates should be furnished by the Medical Practitioner who ordinarily attended him during those three years. A statement will also be required from his Employer, or Employers, in respect of the three years prior to his joining the particular Force
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7. Give the names of the hospitals where the Deceased was treated for the disability (or disabilities) stated in reply to Question 2 above, and the approximate dates of admissions and discharges, if possible
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|
8. Did the Deceased suffer from the disability (or disabilities) mentioned in above answer to Question 2, or anything like it, prior to Military Service? If so, give details and dates
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9. Was the Deceased at any time prior to joining the Forces a candidate for any appointment which necessitated a medical examination? If so, state the nature of the appointment and the result of the medical examination
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10. Give the names of any hospital, or hospitals, in which the Deceased received treatment as an in-patient or an out-patient prior to the period of his Service, and the nature of the ailment (or ailments) for which treatment was provided.
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11. What was the nature of the employment of Deceased ?—
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(a) Before joining the Irish Volunteers, Irish Citizen Army, or National Army
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(b) During the period of his Service with the Irish Volunteers or Irish Citizen Army
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(c) After the cessation of his Military Service
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12. Give the names and addresses of his Employers :
|
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|
(a) During the three years prior to joining the particular Military Force in which it is claimed he contracted the disability (or disabilities) which caused his death
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(b) During the period of his Service with the Irish Volunteers or Irish Citizen Army
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|
(c) During the period since the cessation of his Military Service and prior to his death
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13. Give particulars of any period, or periods, of unemployment since the cessation of the Military Service of the Deceased, and the cause of it (e.g., trade depression, ill health, etc.)
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14. Did either the Deceased or yourself receive compensation from the Deceased's Employers, or from any person or body in respect of any accident, injury, or disease, and, if so, give full particulars and state the amount of such compensation
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15. Give the names and addresses of any Doctors who attended the Deceased since the cessation of his Military Service
|
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|
16. If the Deceased was treated at a hospital (either as an in-patient or an out-patient) since the cessation of his Military Service, give the name of the hospital, or hospitals, dates of admission, or commencement of treatment, and the nature of the ailment for which treated
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17. Give particulars of the health of Deceased since the cessation of his Military Service. These should be supported by :
|
|
|
(a) Medical certificates from any civilian doctors who attended him and reports from non-Military hospitals which Deceased attended
|
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|
(b) Certificates from Deceased's Employers as to health and time lost
|
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|
18. Have you received, or did the Deceased receive, in respect of the disability, or disabilities, which caused his death any payment :
|
|
|
(a) On a decree under the Criminal Injuries (Ireland) Acts, 1919 and 1920
|
|
|
(b) On an award made by the Personal Injuries Committee
|
|
|
(c) From any relief organisation such as National Aid or White Cross Association. If so, give full particulars
|
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19. Give the name of Deceased's National Health Approved Society, and (if possible) his membership number
|
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|
20. Did the Deceased make a claim for a certificate of service under the
Military Service Pensions Act, 1924
? If so, what was the result of his claim
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| |
21. Give the following particulars of children living :—
|
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(a) Where the Deceased was an Officer :
|
| | |
Full Name of each Son under 18
|
Date of Birth
|
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Full Name of each Daughter under 21
|
Date of Birth
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(Birth Certificates must be attached.)
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(b) Where the Deceased was a Soldier :
|
| | |
Full Name of each Son under 16
|
Date of Birth
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Full Name of each Daughter under 18
|
Date of Birth
|
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(Birth Certificates must be attached.)
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22. State the amount expended within the last twelve months in educational fees on each of the children over twelve years and under eighteen years, mentioned in your reply to Question 21.
|
| | |
Name of Child
|
£ s. d.
|
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(Receipts for School Fees should be attached.)
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| | |
23. State whether your deceased husband was at any time in receipt of a pension, allowance, or gratuity in respect of injuries received or disability incurred in the course of Service with any of the following Military or Police Forces :
|
|
|
(a) British.
|
|
|
(b) Australian.
|
|
|
(c) New Zealand.
|
|
|
(d) South African.
|
|
|
(e) Canadian.
|
|
|
(f) American (U.S.A.).
|
|
|
(g) Royal Irish Constabulary.
|
|
|
(h) Dublin Metropolitan Police.
|
|
|
(i) Gárda Síochána.
|
|
|
24. Give particulars of any payments you have received from Army Funds since the death of your husband
|
|
|
25. State whether any claim has been made or is being made by you in respect of any member of the Forces
|
|
|
26. Is there any other information which you can give which is material to your claim?
|
|
|
| |
The above statement has been read over by/to me. It is my own statement, and is correct and complete. I have nothing to add to it.
|
| | |
(Signed)............................................................ .............
|
Address............................................................ ........
|
|
(Applicant.)
|
|
(Signed*)............................................................ ..........
|
Address............................................................ ........
|
|
(Witness.)
|
|
Qualification of Witness............................................
|
Date............................................................ ...............
|
|
| |
*To be signed by one of the following:—
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
(SIXTH AND SEVENTH SCHEDULES.)
|
| |
A.P. 30.
|
| |
ARMY PENSIONS ACTS, 1923 AND 1927.
|
| |
APPLICATION FOR DEPENDANT'S ALLOWANCE OR GRATUITY BY OR ON BEHALF OF A DEPENDANT (OTHER THAN WIDOW) UNDER
SECTION 14
of THE
ARMY PENSIONS ACT, 1927
.
|
| |
NOTE.—This form is to be filled in by the Applicant in person in his (or her) own words, and the form is to be signed by him (or her) and the signature witnessed. In the event of the Applicant being unable to write, he (or she) should affix his (or her) mark, such act being witnessed.
|
| | |
NAME OF APPLICANT (To be written in block capitals)
|
|
............................................................ ............................................................ ..........................................................
|
|
|
(Surname—Mr., Mrs. or Miss)
|
(Christian Names).
|
|
Address............................................................ ............................................................ ...........................................
|
|
Nearest Gárda Síochána Station............................................................ ............................................................ ..
|
|
Name of Deceased Member............................................................ ............................................................ .........
|
|
| | |
Rank in
|
|
Irish Volunteers............................................................ ............................................................ .
|
|
Irish Citizen Army, 1916............................................................ ...............................................
|
|
National Army............................................................ ............................................................ ...
|
|
Unit and Corps............................................................ Army No............................................................ ...............
|
|
Name and Rank of Commanding Officer............................................................ ................................................
|
|
............................................................ ............................................................ ..........................................................
|
|
| |
NOTE.—Before answering any of the questions below, the applicant is to note that the statements made will be checked from official records.
|
| |
Section 12 (1) of the Act imposes a summary penalty for a false declaration:
|
| |
" Every person who, with a view to obtaining the grant or payment of a pension, allowance, or gratuity under this Act, either for himself or for any other person, makes, signs, or uses any declaration, application, or other written statement, knowing the same to be false, shall be guilty of an offence under this section, and shall be liable on summary conviction thereof to a fine not exceeding twenty-five pounds or, at the discretion of the court, to imprisonment for any term not exceeding six months, or to both such fine and such imprisonment."
|
| |
If the Applicant is unable to read, the above notes should be read over to him (or her) by the witness, who should so testify in his attestation of the claim.
|
| | |
1. State your relationship to the Deceased.
|
|
|
2. State the date of your birth. (If you are the father of the Deceased and claim to be over 60 years of age, your Birth Certificate must be forwarded)
|
|
|
3. When and where did the Deceased die, and what was the cause or causes of death? (Certificate of death to be attached.)
|
|
|
4. State whether the Deceased was married
|
|
|
5. State whether you were, at the date of death of the Deceased, wholly dependent on him. If not wholly dependent, state the extent to which you were dependent
|
|
|
6. If the Applicant is the brother or sister of the Deceased, or the father of the Deceased, and under 60 years of age state whether and, if so, how far you are incapacitated by ill-health. (Certificate from your doctor must be attached.)
|
|
|
7. State whether any claim has been made, or is being made by you, in respect of any other member of the Forces
|
|
|
8. In what way do you claim that the disability (or disabilities) which was the cause of death, was connected with the Military Service of the Deceased? What grounds have you for the claim? (A detailed statement of the facts, with dates, should be given.)
|
|
|
9. State for what period Deceased served in:
|
|
|
Irish Volunteers
|
|
|
Irish Citizen Army
|
|
|
National Army
|
|
|
Defence Forces
|
|
|
(a) When, and in what area or areas, did the disability (or disabilities) which resulted in death commence?
|
|
|
(b) Who was the Deceased's Commanding Officer or Officers in the several Forces?
|
|
|
(c) Give the names of any persons who can corroborate your answer to (a) above
|
|
|
(d) If Deceased served in the National Army or Defence Forces, state the date of discharge from the Army or Forces
|
|
|
10. Were there any particular conditions affecting the service of the Deceased which you claim caused the disability (or disabilities)
|
|
|
11. Give particulars of the health of the Deceased for the three years prior to joining the particular Force in which it is claimed he incurred the disability or disabilities which caused his death. If possible, certificates should be furnished :
|
|
|
(a) From his doctor; and
|
|
|
(b) From his Approved Society for the three years prior to his joining the particular Force, or, if he was not an insured person, certificates should be furnished by the Medical Practitioner who ordinarily attended him during those three years. A statement will also be required from his Employer, or Employers, in respect of the three years prior to his joining the particular Force
|
|
|
12. Give the names of the hospitals where the Deceased was treated for the disability (or disabilities) stated in reply to Question 3 above, and the approximate dates of admissions and discharges, if possible
|
|
|
13. Did the Deceased suffer from the disability (or disabilities) mentioned in above answer to Question 3, or anything like it, prior to Military Service ? If so, give details and dates
|
|
|
14. Was the Deceased at any time prior to joining the Forces a candidate for any appointment which necessitated a medical examination ? If so, state the nature of the appointment and the result of the medical examination
|
|
|
15. Give the names of any hospital or hospitals in which the Deceased received treatment as an in-patient or an out-patient, prior to the period of his service, and the nature of the ailment or ailments for which treatment was provided
|
|
|
16. What was the nature of the employment of Deceased :
|
|
|
(a) Before joining the Irish Volunteers, Irish Citizen army, or National Army
|
|
|
(b) During the period of his service with the Irish Volunteers or Irish Citizen Army
|
|
|
(c) After the cessation of his Military Service
|
|
|
17. Give the names and addresses of his Employers :
|
|
|
(a) During the three years prior to joining the particular Military Force in which it is claimed he contracted the disability (or disabilities) which caused his death.
|
|
|
(b) During the period of his Service with the Irish Volunteers or Irish Citizen Army
|
|
|
(c) During the period since the cessation of his Military Service and prior to his death
|
|
|
18. Give particulars of any period or periods of unemployment since the cessation of the Military Service of the Deceased, and the cause of it (e.g., trade depression, ill-health, etc.)
|
|
|
19. Did either the Deceased or yourself receive compensation from the Deceased's employers, or from any person in respect of any accident, injury or disease and, if so, give full particulars and state the amount of such compensation
|
|
|
20. Give the names and addresses of any doctors who attended the Deceased since the cessation of his Military Service
|
|
|
21. If the Deceased was treated at a hospital (either as an in-patient or an out-patient) since the cessation of his Military Service, give the name of the hospital or hospitals, dates of admission, or commencement of treatment, and the nature of the ailment for which treated
|
|
|
22. Give particulars of the health of Deceased since the cessation of his Military Service. These should be supported by :
|
|
|
(a) Medical certificates from any civilian doctors who attended him, and reports from non-Military hospitals which Deceased attended
|
|
|
(b) Certificates from Deceased's employers as to health and time lost
|
|
|
23. Have you received, or did the Deceased receive, in respect of the disability (or disabilities) which caused his death, any payment
|
|
|
(a) On a decree under the Criminal Injuries (Ireland) Acts, 1919 and 1920
|
|
|
(b) On an award made by the Personal Injuries Committee
|
|
|
(c) From any relief organisation, such as National Aid or White Cross Association ? If so, give full particulars
|
|
|
24. Give the name of Deceased's National Health Approved Society, and (if possible) his membership number
|
|
|
25. Did the Deceased make a claim for a certificate of service under the
Military Service Pensions Act, 1924
? If so, what was the result of this claim
|
|
|
26. State whether Deceased was at any time in receipt of a pension, allowance or gratuity in respect of injuries received or disability incurred in the course of service with any of the following Military or Police Forces :
|
|
|
(a) British
|
|
|
(b) Australian
|
|
|
(c) New Zealand
|
|
|
(d) South African
|
|
|
(e) Canadian
|
|
|
(f) American (U.S.A.)
|
|
|
(g) Royal Irish Constabulary
|
|
|
(h) Dublin Metropolitan Police
|
|
|
(i) Gárda Síochána
|
|
|
27. Give particulars of any payments you have received from Army Funds since the death of Deceased
|
|
|
28. If you are supporting any children of the Deceased, give particulars as follows :
|
|
|
| |
(a) Where the Deceased was an Officer :
|
| | |
Full Name of each Son under 18
|
Date of Birth
|
|
|
|
|
| | |
Full Name of each Daughter under 21
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
(b) Where the Deceased was a Soldier :
|
| | |
Full Name of each Son under 16
|
Date of Birth
|
|
|
|
|
| | |
Full Name of each Daughter under 18
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
29. State the amount expended within the past twelve months in educational fees on each of the children over twelve years and under eighteen years, mentioned in your reply to Question 28.
|
| |
|
| |
(Receipts for School Fees should be attached.)
|
| |
The above statement has been read over by/to me. It is my own statement, and is correct and complete. I have nothing to add to it.
|
| | |
(Signed)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Applicant.)
|
|
(Signed*)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Witness.)
|
|
Qualification of Witness
|
..........................................
|
Date
|
............................................................ ....
|
|
| |
* To be signed by one of the following :—
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
(SIXTH AND SEVENTH SCHEDULES.)
|
| |
A.P. 31.
|
| |
ARMY PENSIONS ACTS, 1923 AND 1927.
|
| |
WOUND PENSION OR GRATUITY.
|
| |
APPLICATION BY AN EX-OFFICER OR EX-SOLDIER OR EX-VOLUNTEER FOR A WOUND PENSION OR GRATUITY IN RESPECT OF A WOUND OR INJURY INCURRED IN THE COURSE OF HIS DUTY BEFORE THE 1ST OCTOBER, 1924, UNDER SECTION 1 OR
SECTION 3
of THE
ARMY PENSIONS ACT, 1923
, AS AMENDED BY THE
ARMY PENSIONS ACT, 1927
, OR
SECTION 11
of THE
ARMY PENSIONS ACT, 1927
.
|
| |
The questions are to be answered in the ex-Officer's or ex-Soldier's own words, and the form is to be signed by him and the signature witnessed. In the event of the ex-Soldier being unable to write, he should affix his mark, such act being witnessed.
|
| | |
Army No.
|
.........................................................
|
Rank
|
............................................................ ............
|
|
Unit and Corps
|
............................................................ ............................................................ ..................
|
|
Name and Rank of Commanding Officer
|
............................................................ ......................................
|
|
............................................................ ............................................................ .........................................................
|
|
(Name (To be written in block capitals)
|
............................................................ ......................................
|
|
|
(Surname)
|
(Christian Names.)
|
|
Present Address
|
............................................................ ............................................................ ..................
|
|
Nearest Gárda Síochána Station
|
............................................................ ......................................................
|
|
| |
NOTE.—Before answering the questions below, the applicant is to note that :
|
| |
(a) The statement made by him will be checked from official records.
|
| |
Section 12 (1) of the Act imposes a summary penalty for a false declaration :
|
| |
" Every person who, with a view to obtaining the grant or payment of a pension, allowance, or gratuity under this Act, either for himself or for any other person, makes, signs, or uses any declaration, application, or other written statement knowing the same to be false, shall be guilty of an offence under this Section, and shall be liable on summary conviction thereof to a fine not exceeding twenty-five pounds or, at the discretion of the court, to imprisonment for any term not exceeding six months or to both such fine and such imprisonment."
|
| |
(b) In answering Question 2 (a) any special matters which, in his opinion, caused any unfitness from which he may be suffering, should be clearly stated.
|
| |
If the applicant is unable to read, the above notes should be read over to him by the witness, who should so testify in his attestation of the claim.
|
| | |
1. (a) For what period have you served
|
|
(b) In what area or areas
|
|
2. (a) State the nature of any wound or injury from which you are suffering, the date upon which, and the place and circumstances in which it was received
|
|
(b) Who was your Commanding Officer upon that date
|
|
(c) Give the name of any witnesses who can corroborate your answer to (a) above
|
|
(d) State the date upon which you were discharged from the Army or Defence Forces
|
|
3. Give the names of any hospitals where you have been treated for the above wound or injury, and the approximate dates of admissions and discharges (if possible)
|
|
4. Did you suffer from the injury mentioned in above answer to Question 2 (a), or anything like it before joining the Army or Defence Forces. If so, give details and dates
|
|
5. Give the names and addresses of any hospitals you were in, or doctors who attended you before you joined the Army or Defence Forces
|
|
6. What is the name and address of your last employer before joining the Army or Defence Forces
|
|
7. What was your occupation or trade before joining the Army or Defence Forces
|
|
8. Have you received in respect of the wound or injury mentioned in above reply to Question 2 (a) any compensation from or on behalf of the person alleged to be responsible for the act which caused the wound or injury ? If so, give full particulars
|
|
9. Have you received in respect of the wound or injury mentioned in the answer to Question 2 (a), any payment from any other source
|
|
10. Give the name of your National Health Approved Society, and (if possible) your membership number
|
|
11. Give particulars of any pension or gratuity awarded to you under the
Army Pensions Act, 1923
, in respect of a wound or injury received in the course duty with the Irish Volunteers, Irish Citizen Army, 1916, or National Army
|
|
12. Have you served at any period with any of the following Military or Police Forces ? If so, give particulars of service :
|
|
(a) British.
(b) Australian.
(c) New Zealand.
(d) South African.
(e) Canadian.
( f ) American (U.S.A.)
(g) Royal Irish Constabulary.
(h) Dublin Metropolitan Police.
(i) Gáreda Siochána.
|
|
13. (a) Give full particulars of any pension, allowance or gratuity which you hold, or at any time have held in respect of any wound or injury received in or disease contracted in the services mentioned in your reply to above Question 12.
|
|
(b) State clearly the source from which payment of such pension allowance or gratuity is made or has been made
|
|
| |
The above statement has been read over by/to me. It is my own statement, and is correct and complete. I have nothing further to add to it.
|
| | |
(Signed)
|
............................................................ ..
|
Address
|
........................................................
|
|
(ex-Officer or ex-Soldier)
|
|
(Signed*)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Witness.)
|
|
Qualification of Witness
|
..........................................
|
Date
|
............................................................ ....
|
|
| |
*To be signed by one of the following —:
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
ARMY PENSIONS ACTS, 1923 AND 1927.
|
| |
STATEMENT BY AN EX-OFFICER OR EX-SOLDIER WHO CLAIMS AS A MARRIED MAN A FURTHER PENSION IN ACCORDANCE WITH THE TERMS OF THE ACTS.
|
| | |
14. If your wife is alive :
|
|
(a) State the date of your marriage
|
|
(b) Is your wife dependent on you
|
|
(c) Does she ordinarily reside with you (Certificate of marriage to be attached.)
|
|
15. (a) If your wife is dead or the marriage has been dissolved, state the names and ages of any (To be filled in by ex-Officers) Sons under 18 years of age
Daughters under 21 years of age (To be filled in by ex-Soldiers)
Sons under 16 years
Daughters under 18 years
(Certificate of birth of living children to be attached).
|
|
(b) State whether the child or children mentioned above are dependent on you, and where they are living
(c) State whether any of the above children are married
|
|
16. If your wife is alive, but your marriage has been dissolved, and you claim a further pension in respect of the children mentioned in the reply to Question 15 (a) above, please furnish copy of the decree or order of the Court
|
|
| |
The above statement has been read over by/to me. I agree to it, and have nothing further to add to it.
|
| | |
(Signed)
|
............................................................ ..
|
Address
|
........................................................
|
|
(ex-Officer or ex-Soldier)
|
|
(Signed*)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Witness.)
|
|
Qualification of Witness
|
..........................................
|
Date
|
............................................................ ....
|
|
| |
*To be signed by one of the following —:
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
SIXTH SCHEDULE.
|
| |
A.P. 32.
|
| |
ARMY PENSIONS ACTS, 1923 AND 1927.
|
| |
APPLICATION BY A WIDOW FOR AN ALLOWANCE OR GRATUITY FOR HERSELF OR FOR HERSELF AND CHILDREN, UNDER
SECTION 15
(1) OF THE
ARMY PENSIONS ACT, 1927
.
|
| |
NOTE.—This form is to be filled in by the Applicant in person, in her own words, and the form is to be signed by her and the signature witnessed. In the event of the Applicant being unable to write, she should affix her mark, such act being witnessed.
|
| | |
Name of Applicant (To be written in block capitals)
|
............................................................ .....................
|
|
|
(Surname)
|
(Christian Name)
|
|
Address
|
............................................................ ............................................................ ...................................
|
|
Nearest Gárda Síochána Station
|
............................................................ ......................................................
|
|
Name of deceased Officer or Soldier
|
............................................................ ................................................
|
|
Army Number
|
............................................................ ............................................................ ..................
|
|
Rank
|
............................................................ ............................................................ .........................................
|
|
Unit and Corps
|
............................................................ ............................................................ ..................
|
|
| |
NOTE.—Before answering any of the questions below, the Applicant is to note that the statements made will be checked from official records.
|
| |
Section 12 (1) of the Act imposes a summary penalty for a false declaration.
|
| |
" Every person who, with a view to obtaining the grant or payment of a pension, allowance or gratuity under this Act, either for himself or for any other person, makes, signs, or uses any declaration, application, or other written statement, knowing the same to be false, shall be guilty of an offence under this Section, and shall be liable on summary conviction thereof to a fine not exceeding twenty-five pounds or, at the discretion of the court, to imprisonment for any term not exceeding six months or to both such fine and such imprisonment."
|
| |
If the Applicant is unable to read, the above notes should be read over to her by the witness, who should so testify in his attestation of the claim.
|
| | |
1. Give the date of your marriage to the Deceased. (Certificate of marriage to be attached)
|
|
2. When and where was the Deceased killed. (Certificate of death to be attached)
|
|
3. If the Deceased received, in the course of duty, a wound or injury which was the sole cause of his death subsequently, state :
|
|
(a) The nature of the wound or injury
|
|
(b) The date upon which the wound or injury was received
|
|
(c) The district in which it was received ; and
|
|
(d) Any other circumstances within your knowledge
|
|
(e) Did Deceased receive any pension or gratuity in respect of his wound or injury
|
|
4. Give the names and addresses of any hospitals your deceased husband was in or doctors who attended him since the receipt of the wound or injury referred to in your reply to above Question 3
|
|
5. Give the following particulars of children living
|
|
(a) Where the Deceased was an Officer :
|
|
| | |
Full Name of each Son under 18
|
Date of Birth
|
|
|
|
|
| | |
Full Name of each Daughter under 21
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
(b) Where the Deceased was a Soldier :
|
| | |
Full Name of each Son under 16
|
Date of Birth
|
|
|
|
|
Full Name of each Daughter under 18
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
6. State the amount expended within the last twelve months in educational fees on each of the children over twelve years and under eighteen years, mentioned in your reply to Question 5.
|
| |
|
| |
(Receipts for School Fees should be attached.)
|
| | |
7. State whether any compensation has been paid from or on behalf of any person alleged to be responsible for the act which caused the death, or the wound, or injury referred to in your reply to Questions 2 or 3. If so, give full particulars.
|
|
8. Have you received in respect of the wound or injury mentioned in the answer to Questions 2 and 3 any payment from any other source
|
|
9. State whether your deceased husband was at any time in receipt of a pension, allowance or gratuity in respect of injuries received or disability incurred in the course of service with any of the following Military or Police Forces :
|
|
(a) British.
|
|
(b) Australian.
|
|
(c) New Zealand.
|
|
(d) South African.
|
|
(e) Canadian.
|
|
(f) American (U.S.A.)
|
|
(g) Royal Irish Constabulary.
|
|
(h) Dublin Metropolitan Police.
|
|
(i) Gárda Síochána.
|
|
10. Give particulars of any payments you have received from Army Funds since the death of your husband
|
|
11. State whether any claim has been or is being made by you in respect of any other member of the Forces
|
|
| |
The above statement has been read over by/to me. It is my own statement, and is correct and complete. I have nothing to add to it.
|
| | |
(Signed)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Applicant.)
|
|
(Signed*)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Witness.)
|
|
Qualification of Witness
|
..........................................
|
Date
|
............................................................ ....
|
|
| |
*To be signed by one of the following :—
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
(SIXTH AND SEVENTH SCHEDULES.)
|
| |
A.P. 33.
|
| |
ARMY PENSIONS ACTS, 1923 AND 1927.
|
| |
APPLICATION BY OR ON BEHALF OF A DEPENDANT OTHER THAN A WIDOW FOR AN ALLOWANCE OR GRATIITY UNDER
SECTION 15
of THE
ARMY PENSIONS ACT, 1927
.
|
| |
NOTE.—This form is to be filled in by the Applicant in person — who, in the case of motherless children, will be the Guardian—in his (or her) own words, and the form is to be signed by him (or her) and the signature witnessed. In the event of the Applicant being unable to write, he (or she) should affix his (or her) mark, such act being witnessed.
|
| | |
Name of Applicant (To be written in block capitals)
|
............................................................ .....................
|
|
(Surname.)
|
(Mr., Mrs., or Miss.)
|
|
(Christian Names.)
|
|
Address
|
............................................................ ............................................................ ...................................
|
|
Nearest Gárda Síochána Station
|
............................................................ ......................................................
|
|
Name of Deceased Officer or Soldier
|
............................................................ ...................................
|
|
Army Number
|
............................................................ ............................................................ ........................
|
|
Rank
|
............................................................ ............................................................ .........................................
|
|
Unit and Corps
|
............................................................ ............................................................ ........................
|
|
Name and Rank of Commanding Officer
|
............................................................ ...................................
|
|
............................................................ ............................................................ .........................................................
|
|
| |
NOTE.—Before answering any of the questions below, the Applicant is to note that the statements made will be checked from official records.
|
| |
Section 12 (1) of the Act imposes a summary penalty for a false declaration :
|
| |
" Every person who, with a view to obtaining the grant or payment of a pension, allowance, or gratuity under this Act, either for himself or for any other person, makes, signs, or uses any declaration, application, or other written statement, knowing the same to be false, shall be guilty of an offence under this Section, and shall be liable on summary conviction thereof to a fine not exceeding twenty-five pounds or, at the discretion of the court, to imprisonment for any term not exceeding six months, or to both such fine and such imprisonment."
|
| |
If the Applicant is unable to read, the above notes should be read over to him (or her) by the witness, who should so testify in his attestation of the claim.
|
| | |
1. State your relationship to the Deceased
|
|
2. State the date of your birth. (If you are the father of the Deceased and claim to be over 60 years of age, your Birth Certificate must be forwarded)
|
|
3. When and where was the Deceased killed ? (Certificate of death to be attached)
|
|
4. If the Deceased received in the course of duty a wound or injury which was the sole cause of his death subsequently, state :
|
|
(a) The nature of the wound or injury
|
|
(b) The date upon which the wound or injury was received
|
|
(c) The district in which it was received ; and
|
|
(d) Any other circumstances within your knowledge
|
|
5. State whether the Deceased was married
|
|
6. Give the names and addresses of any hospitals the Deceased was in, or doctors who attended him since the receipt of the wound or injury mentioned in your reply to above Question 4
|
|
7. State whether you were, at the date of the death of the Deceased, wholly dependent on him. If not wholly dependent, state the extent to which you were dependent.
|
|
8. If the Applicant is the brother or sister of the Deceased, or the father of the Deceased, and under 60 years of age state whether and, if so, how far you are incapacitated by ill-health. (Certificate from your doctor must be attached)
|
|
9. State whether any claim has been made, or is being made by you, in respect of any other member of the Forces
|
|
10. State whether any compensation has been paid from or on behalf of any person alleged to be responsible for the act which caused the death wound or injury referred to in your reply to above Questions 3 or 4. If so, give full particulars
|
|
Have you or has anybody else received in respect of the wound or injury mentioned in the answer to Questions 3 or 4 any payment from any other source ?
|
|
11. State whether Deceased was at any time in receipt of a pension, allowance or gratuity in respect of injuries received or disability incurred in the course of service with any of the following Military or Police Forces
|
|
(a) British.
|
|
(b) Australian.
|
|
(c) New Zealand.
|
|
(d) South African.
|
|
(e) Canadian.
|
|
( f ) American (U.S.A.)
|
|
(g) Royal Irish Constabulary.
|
|
(h) Dublin Metropolitan Police.
|
|
(i) Gárda Síochána.
|
|
12. Give particulars of any payments you have received from Army Funds since the death of Deceased
|
|
13. If you are supporting any children of the Deceased give particulars as follows :
|
|
(a) Where the Deceased was an Officer :
|
|
| | |
Full Name of each Son under 18
|
Date of Birth
|
|
|
|
|
| | |
Full Name of each Daughter under 21
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
(b) Where the Deceased was a Soldier :
|
| | |
Full Name of each Son under 16
|
Date of Birth
|
|
|
|
|
| | |
Full Name of each Daughter under 18
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
14. State the amount expended within the last twelve months in educational fees on each of the children over twelve years and under eighteen years, mentioned in your reply to Question 13.
|
| |
|
| |
(Receipts for School Fees should be attached.)
|
| |
The above statement has been read over by/to me. It is my own statement. I have nothing to add to it.
|
| | |
(Signed)
|
............................................................ ......
|
Address
|
............................................................
|
|
(Applicant.)
|
|
(Signed*)
|
............................................................ ......
|
Address
|
............................................................
|
|
(Witness.)
|
|
Qualification of Witness
|
.....................................
|
Date
|
............................................................ ....
|
|
| |
*To be signed by one of the following :—
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
(THIRD SCHEDULE.—WOUNDS.)
|
| |
A.P. 34.
|
| |
ARMY PENSIONS ACT, 1927
.
|
| |
APPLICATION BY A PERSON CLAIMING A WOUND PENSION UNDER SECTION 12 OF THE ACT.
|
| |
NOTE.—This statement is to be filled in by the Applicant, or for him should he be illiterate. (The Applicant's statement will be checked from official records.)
|
| | |
1. Name
|
|
|
2. Address
|
|
|
3. Age
|
|
|
4. State the nature of the wound or injury from which you are suffering
|
|
|
5. When and where and in what circumstances was it received
|
|
|
6. In what Batallion were you serving at the time ? State your Army Number.
|
|
|
7. Give the names of any hospitals in which you were treated for the above wounds or injury, and the approximate dates of admission and discharge.
|
|
|
8. Give the date of your resignation or discharge from the Defence Forces
|
|
|
9. Have you received in respect of the wound or injury mentioned above any compensation from or on behalf of the person alleged to be responsible for the act which caused the wound or injury. If so, give full particulars
|
|
|
10. Give particulars of any pension or gratuity awarded to you under the
Army Pensions Act, 1923
, in respect of a wound or injury received in the course of duty with the Irish Volunteers, Irish Citizen Army, 1916, or National Army.
|
|
|
11. If you are a married man :
|
|
|
(a) State the date of your marriage
|
|
|
(b) Is your wife dependent on you?
|
|
|
(c) Does she ordinarily reside with you?
(Certificate of marriage to be attached.)
|
|
|
12. (a) If your wife is dead, or the marriage has been dissolved, state the names and ages of any (To be filled in by ex-Officers) Sons under 18 years of age
|
|
|
Daughters under 21 years of age (To be filled by ex-Soldiers) Sons under 16 years of age
Daughters under 18 years of age (Certificates of birth to be attached.)
|
|
|
(b) State whether the child or children mentioned above are dependent on you, and where they are living
|
|
|
(c) State whether any of the above children are married
|
|
|
13. If your wife is alive, but your marriage has been dissolved, and you claim a further pension in respect of the children mentioned in reply to question 12 above, please furnish copy of the decree or order of the Court
|
|
|
| |
The above statement has been read over by/to me. It is my own statement, and is correct and complete. I have nothing to add to it.
|
| | |
(Signed)
|
............................................................ ..
|
Address
|
............................................................
|
|
(ex-Officer or ex-Soldier.)
|
|
(Signed*)
|
............................................................ ..
|
Address
|
............................................................
|
|
(Witness.)
|
|
Qualification
|
........................................................
|
Date
|
............................................................ ........
|
|
| |
*To be signed by one of the following :—
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.
|
| |
A member of the Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
| |
(SEVENTH SCHEDULE.)
|
| |
A.P. 35.
|
| |
ARMY PENSIONS ACT, 1927
.
|
| |
APPLICATION BY A WIDOW FOR AN ALLOWANCE FOR HERSELF OR FOR HERSELF AND CHILDREN UNDER SECTION 15 (2) OF THE ACT.
|
| |
NOTE.—This statement is to be filled in by the Applicant or for her, should she be illiterate. (The Applicant's statement will be checked from Official records).
|
| |
In the case of Motherless children, the Applicant will be the Guardian.
|
| | |
1. Name
|
|
|
2. Address
|
|
|
3. Name of deceased Officer or Soldier
|
|
|
4. Army Number
|
|
|
5. Rank
|
|
|
6. Unit and Corps
|
|
|
7. Give the date of marriage of deceased
(Certificate of marriage to be attached).
|
|
|
8. When and where, and in what circumstances, was the deceased killed
|
|
|
9. If the deceased received in the course of duty a wound or injury which was the sole cause of his death subsequently, state :—
|
|
|
(a) the nature of the wound or injury
|
|
|
(b) the date upon which the wound or injury was received
|
|
|
(c) the district in which it was received, and
|
|
|
(d) any other circumstances within your knowledge
|
|
|
10. Give the names and addresses of any hospitals the deceased was in, or doctors who attended him since the receipt of the wound or injury referred to in your reply to above question 9
|
|
|
11. Give the following particulars of children living :—
|
|
|
(a) Where the Deceased was an Officer :
|
|
|
| | |
Full Name of each Son under 18
|
Date of Birth
|
|
|
|
|
| |
i
|
| | |
Full Name of each Daughter under 21
|
Date of Birth
|
|
|
|
|
| |
(Birth Certificates must be attached.)
|
| |
(b) State the amount expended within the last twelve months in educational fees on each of the children over eleven years and under eighteen years, mentioned in your reply to Question 11.
|
| |
|
| |
(Receipts for School fees should be attached.)
|
| |
(c) Where the Deceased was a Soldier :
|
| | |
Full Name of each Son under 16
|
Date of Birth
|
|
|
|
|
| | |
Full Name of each Daughter under 18
|
Date of Birth
|
|
|
|
|
(Birth Certificates must be attached.)
|
|
| | |
12. State whether any compensation has been paid from or on behalf of any person alleged to be responsible for the act, which caused the death, wound, or injury, referred to in your reply to above questions 8 and 9. If so, give full particulars
|
|
13. Give particulars of any payments you have received from Army Funds since the death of the deceased
|
|
| |
This statement has been read over by/to me. It is my own statement, and is correct and complete. I have nothing to add to it.
|
| | |
(Signed*)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Applicant.)
|
|
(Signed*)
|
............................................................ ..
|
Address
|
........................................................
|
|
(Witness.)
|
|
Qualification of Witness
|
.......................................
|
Date
|
............................................................ ....
|
|
| |
To be signed by one of the following :—
|
| |
A Commissioned Officer serving in the Defence Forces.
|
| |
A permanent Civil Servant (active or retired) whose salary is or was not less than £200 and on a scale rising to not less than £300.
|
| |
A District Justice.
|
| |
A Peace Commissioner.
|
| |
A Barrister-at-Law, a Solicitor, or a Commissioner for Oaths.
|
| |
A Minister of Religion (denomination to be stated).
|
| |
A Registered Physician or Surgeon.
|
| |
Managers, Secretaries, Chief Cashiers and Accountants of Banks, and Officials in charge of Branch Banks.
|
| |
A member of Gárda Síochána.
|
| |
A Postmaster or Postmistress in actual charge of a Post Office.
|
| |
Head Teachers of Secondary or National Schools.
|
| |
A Secretary of a Registered Friendly Society.
|
