S.I. No. 181/1933 - Army Pensions (Forms of Application) Regulations, 1933.

STATUTORY RULES AND ORDERS. 1933. No. 181.

ARMY PENSIONS (FORMS OF APPLICATION) REGULATIONS, 1933.

WHEREAS by virtue of Section 20 of the Army Pensions Act, 1932 (No. 24 of 1932), every application for the grant of a pension, allowance, or gratuity under Part II of the said Act is required to be made to the Minister for Defence in the prescribed form and to contain the prescribed particulars, and by virtue of the said section the Minister for Defence is empowered by order to make regulations prescribing the said form and particulars :

NOW, I, FRANK AIKEN, Minister for Defence, in exercise of the powers conferred on me by virtue of Section 20 of the Army Pensions Act, 1932 (No. 24 of 1932), and of every and any other power me in this behalf enabling, do hereby order and make the following regulations, that is to say :—

1. These regulations may be cited for all purposes as the Army Pensions (Forms of Application) Regulations, 1933.

2. In these regulations the expression " the Act of 1932 " means the Army Pensions Act, 1932 (No. 24 of 1932).

3. The Interpretation Act, 1923 (No. 46 of 1923), applies to the interpretation of these Regulations in like manner as it applies to the interpretation of an Act of the Oireachtas.

4. Every application for the grant of a pension or gratuity under Section 10 of the Act of 1932 shall be in the Form No. A.P. 50 in the Schedule hereto, and shall contain the particulars asked for or otherwise indicated in that Form.

5. Every application for the grant of an allowance or gratuity under Section 12 or Section 13 of the Act of 1932, in respect of the death of a person, to the widow or a child of such person shall be made in the Form No. A.P. 51 in the Schedule hereto, and shall contain the particulars asked for or otherwise indicated in that Form.

6. Every application for the grant of an allowance or gratuity under Section 12 of the Act of 1932, in respect of the death of a person, to a dependant (not being the widow or a child) of such person shall be made in the Form No. A.P. 52 in the Schedule hereto, and shall contain the particulars asked for or otherwise indicated in that Form.

Given under my Seal of Office this 5th day of

January, 1933.

FRANK AIKEN,

Minister for Defence.

SCHEDULE.

A.P. 50.

ARMY PENSIONS ACT, 1932 .

APPLICATION FOR A WOUND OR DISEASE PENSION OR A GRATUITY UNDER SECTION 10 of THE ARMY PENSIONS ACT, 1932 .

INSTRUCTIONS FOR USE OF THIS FORM.

1. In every case the name to be inserted as applicant is that of the person by whom or on whose behalf it is claimed that he is entitled to the pension or gratuity.

2. This application form is to be signed by the applicant, except where the Minister for Defence authorises it to be signed on behalf of the applicant by another person.

3. The attention of the person signing this form is directed to the declaration at the foot hereof to be made by such person.

4. The signature of the person signing this form is to be attested by a witness. (As to who may be a witness, see foot of this form.)

5. In the event of the person making the application being unable to write, he or she is to sign by affixing his or her mark and the attesting witness is to insert the name of such person.

Name of Applicant	(To be............................................................ .................................................
	written (Surname)
	in Block
	Capitals)............................................................ ............................................
	(Christian Names)
Age last Birthday ............................................................ ............................................................ ................................
Present Address ............................................................ ............................................................ ..................................
Nearest Gárda Síochána Station ............................................................ ............................................................ ........
Distance of Nearest Railway Station from Residence ............................................................ ...............................
Distance of Nearest Bus Route from Residence ............................................................ .........................................
Whether Railway or Bus is the more economical method of Transport between Residence and Dublin ............................................................ ............................................................ ..........................

NOTE.—Before answering the questions below, the person making the declaration at the foot of this form is to note that :—

(a) The statement made by him will be checked.

The Army Pensions Act, 1932 , 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 Part II of the Army Pensions Act, 1932 , 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."

( Section 12 (1) of Army Pensions Act, 1923 , as applied by Army Pensions Act, 1932 .)

(b) In answering question 3D (1) any special circumstances involved in applicant's service which, it is considered, caused any unfitness from which he may be suffering should be clearly stated.

If the declarant 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. Give particulars of applicant's service in any of the undermentioned Organisations :—

ORGANISATION	Period of Service*		In what capacity he served	In what areas he served	Name of his Commanding Officer
	From	To
(a) Oglaigh na h-Eireann
(Irish Republican Army)
(b) Irish Volunteers
(c) Irish Citizen Army
(d) Fianna Eireann
(e) Hibernian Rifles
( f ) Cumann na mBan

* If the Service was not continuous throughout particulars of the period or periods of actual military service should be stated.

2. What is the nature of any wound or disease for which applicant now claims a pension ?

3. (a) When, where, and in what circumstances was any such wound received or such disease contracted ?

(b) Who was applicant's Commanding Officer at the time ?

3D. Replies to questions 3D (i) to (v) to be filled in only by applicants in r espect of Disease

(i) In what way is it claimed that applicant's disease is connected with his Military Service, and what are the grounds for the claim ?

(A detailed statement of the facts with dates should be given.)

(ii) Were there any particular conditions affecting applicant's service which it is claimed caused the disability or disabilities ? Did the applicant suffer from any illness during the period of his service ? If so, give particulars, including any treatment received.

(iii) Give particulars of the applicant's health for the 3 years prior to joining the particular Force in which it is claimed he incurred the disability (or disabilities). If possible, certificates should be furnished :—

(a) from his doctor, and

(b) from his approved Society for the 3 years prior to 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 these 3 years. A statement will also be required from his Employer or Employers in respect of the 3 years prior to his joining the particular Force.

(iv) Give the names and addresses of the applicant's Employers :—

(a) During the 3 years prior to joining the particular Military Force in which it is claimed he contracted any disability referred to in the reply to Question 2 above.

(b) During the period of his Military Service referred to at 1.

(v) Was the applicant at any time prior to his service referred to at 1, 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.

4. Give the names of the hospitals where the applicant has been treated for any Wound or Disease stated in reply to Question 2 above, and the approximate dates of admissions and Discharges.

5. Did the applicant suffer from any Wound or Disease mentioned in above answer to Question 2, or anything like it, prior to his service as stated in reply to Question 1? If so, give details and dates.

6. Give the names of any hospitals in which the applicant received treatment as an in-patient or an out-patient, prior to the period of his service, and the nature of the ailment for which treatment was provided.

7. What was the nature of the applicant's employment ?

(a) Before his Military Service referred to at 1. (State name and address of last employer.)

(b) During the period of his Military Service referred to at 1.

8. Give particulars of any period, or periods, of unemployment since the cessation of the applicant's Military Service, and the cause of it (e.g., trade depression, ill-health, etc.).

9. Has the applicant received compensation from his Employer, or from any person or body in respect of any accident, injury, or disease. If so, give full particulars and state the amount of such compensation.

10. Give the names and addresses of any doctors who attended the applicant since the cessation of his Military Service, and particulars of the ailments for which they attended him.

11. If the applicant has been 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.

12. Give particulars of the applicant's health since the cessation of his Military Service. These should be supported by :—

(a) medical certificates from any civilian doctors who have attended him and reports from non-military hospitals he has attended ;

(b) certificates from his employers as to health and time lost.

13. Has the applicant received, in respect of any wound or disease mentioned in answer to Question 2 above, 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 ;

(d) from any other source.

If so, give full particulars.

14. Give the name of the applicant's National Health Approved Society and (if possible) his Membership Number.

15. Has the applicant at any time since the cessation of his Military Service been registered at a Labour Exchange ? If so, give particulars as to the name of the Exchange and the period.

16. Is there any other information which you can give, which is material to the Applicant's claim ?

(Note.— Section 10 (5) of the Army Pensions Act, 1932 .)

17. Did the applicant make a claim for a certificate of Service under the Military Service Pensions Act, 1924 ? If so, what was the result of his claim ?

18. Did the applicant make a claim for a pension or gratuity in respect of any wound or disease referred to at Question 2 above under the Army Pensions Acts, 1923, and 1927 ? If so, what was the result of his claim?

19. Give particulars of any pension or gratuity awarded to the applicant under the Army Pensions Act, 1923 , or under the Army Pensions Act, 1927 , in respect of a wound or injury received or disease contracted in the course of duty with the Irish Volunteers, Irish Citizen Army, 1916, or National Army.

20. Has the applicant served at any period 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 ; (j) National Army ; (k) Defence Forces. If so, give particulars of service.

21. (a) Give full particulars of any pension, allowance or gratuity which the applicant holds, or at any time held in respect of any wound or injury received in or disease contracted in the services mentioned in your reply to above question.

(b) State clearly the source from which payment of such pension, allowance or gratuity is made or has been made.

Additional particulars to be given if by reason of applicant being a married man a further pension in accordance with the terms of the Act is claimed.

22. If applicant's wife is alive :—

(a) State the date of his marriage.

(b) State the name of his wife.

(d) Does she ordinarily reside with him ? (Certificate of marriage to be attached.)

23. (a) If the applicant's wife is dead, or the marriage has been annulled or dissolved, state the names and ages of any :

Sons under 18 years of age.

Unmarried Daughters under 21 years of age.

(Certificates of birth of living children to be attached.)

(b) State whether the children mentioned above are dependent on the applicant, and where they are living.

I declare that—

(a) I am the applicant mentioned in the foregoing particulars.

(b) the said particulars have been read over by or to me before signing this declaration.

Signature of Applicant.........................................................
Address of Applicant...........................................................

or (where application is sent in by another person on behalf of applicant)—

I declare that—

(a) this application is made by me on behalf of the above-mentioned applicant,

(b) that the foregoing particulars have been read over by or to me before signing this declaration,

Signature of Declarant.........................................................

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

Description............................................................ .................

Signature of Witness.............................................	Address............................................................ .....
(See Note overleaf)
Qualification...........................................................	Date............................................................ .

NOTE.—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.

A.P. 51.

ARMY PENSIONS ACT, 1932 .

APPLICATION FOR AN ALLOWANCE OR A GRATUITY UNDER SECTION 12 OR 13 OF THE ARMY PENSIONS ACT, 1932 , IN RESPECT OF DEATH OF A PERSON BY OR ON BEHALF OF WIDOW OR CHILD OF SUCH PERSON.

INSTRUCTIONS FOR USE OF THIS FORM.

1. In every case the name to be inserted as applicant is that of the person by whom or on whose behalf it is claimed that she or he is entitled to the allowance or gratuity.

2. This application form is to be signed by the applicant, except where the Minister for Defence authorises it to be signed on behalf of the applicant by another person.

3. The attention of the person signing this form is directed to the declaration at the foot hereof to be made by such person.

4. The signature of the person signing this form is to be attested by a witness. (As to who may be a witness, see foot of this form.)

5. In the event of the person making the application being unable to write he or she is to sign by affixing his or her mark and the attesting witness is to insert the name of such person.

Name of Applicant			(To be............................................................ ..............................................
			written in				(Surname)
			Block
			Capitals)............................................................ ..............................................
							(Christian Names)
Address	............................................................ ............................................................ ........................
Nearest Gárda Síochána Station					............................................................ ..........................................
Distance of nearest Railway Station from Residence............................................................ ..................
Distance of nearest Bus route from Residence						............................................................ ..........................
Whether Railway or Bus is the more economical method of transport between Residence and Dublin............................................................ ............................................................ ..................................
Name of Deceased Member				............................................................ ...................................................
Late of (Address)		............................................................ ............................................................ .........
		............................................................ ............................................................ .........

NOTE.—Before answering any of the questions below, the person making the declaration at the foot of this Form is to note that the statements made will be checked.

The Army Pensions Act, 1932 , 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 Part II of the Army Pensions Act, 1932 , 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. ( Section 12 (1) of Army Pensions Act, 1923 , as applied by the Army Pensions Act, 1932 .)

If the declarant is unable to read, the above notes should be read over to her or him by the witness, who should so testify in his attestation of the claim.

1. State relationship of applicant to deceased and whichever of following particulars is appropriate :—

(a) If widow, date of marriage (certificate of marriage to be attached).

(b) If child, date of birth (certificate of birth to be attached).

2. (a) When and where did the Deceased die, and what was the cause or causes of death ? (Certificate of Death to be attached).

(b) If the Deceased died as an immediate result of refusing to take nourishment while detained in prison, or died by violence while a prisoner, give details of the date, place and circumstances.

3. Give particulars of the service of the Deceased in any of the under-mentioned Organisations :—

ORGANISATION	Period of Service	In what capacity he served	In what areas he served	Name of his Commanding Officer
From	To
(a) Oglaigh na h-Eireann
(Irish Republican Army)
(b) Irish Volunteers
(c) Irish Citizen Army
(d) Fianna Eireann
(e) Hibernian Rifles
( f ) Cumann na mBan

4. (a) When and in what area did the Deceased receive the wound or injury or contract the disease which resulted in death ?
(b) Who was the deceased's Commanding Officer at the time?
(c) Give the names of any persons who can corroborate your answer to (a) above.
4D. Replies to Questions 4D. (i) to (v) to be filled in only in case of death due to Disease.
i) In what way is it claimed that the disease which was the cause of death was connected with the Military Service of the deceased and what are the grounds for the claim ?
(A detailed statement of the facts with dates should be given.)
(ii) Were there any particular conditions affecting the service of the deceased which it is claimed caused the disability (or disabilities) ? Did the deceased suffer from any illness during the period of his service ? If so, give particulars, including any treatment received.
(iii) 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 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 Employers in respect of the three years prior to his joining the particular force.
(iv) 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 any disability referred to in the reply to Question 2 above.
(b) During the period of his Military Service referred to at 3.
(c) During the period since the cessation of his Military Service.
(v) Was the deceased at any time prior to his service referred to at 3 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.

5. 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.

6. 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.

7. 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 ailments for which treatment was provided.

8. What was the nature of the employment of deceased :—

(a) before his Military Service referred to at 3, or

(b) during the period of such Military Service.

9. 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.).

10 Did either the deceased or the applicant receive compensation from the deceased's Employers, or from any person or body in respect of any accident, injury, or disease ? If so, give full particulars and state the amount of such compensation.

11. Give the names and addresses of any Doctors who attended the deceased since the cessation of his Military Service, and particulars of the ailments for which they attended him.

12. 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.

13. 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.

14. Has the applicant 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;

(d) from any other source;

If so, give full particulars.

15. Give the name of deceased's National Health Approved Society, and (if possible) his membership number.

16. 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 ?

17. Did the applicant, or did the deceased, make any claim under the Army Pensions Acts, 1923 and 1927, in respect of the wound or disease which caused the death of the deceased ? If so, what was the result of such claim ?

18. Give particulars of any pension or gratuity awarded to the deceased under the Army Pensions Acts, 1923 and 1927, in respect of a wound or injury received or disease contracted in the course of duty with the Irish Volunteers, Irish Citizen Army, 1916, National Army or Defence Forces.

19. Give the following particulars of the deceased's children living:—

Full name of each son under 18	Date of Birth

Full name of each unmarried daughter under 21	Date of Birth

(Birth Certificates must be attached.)

20. State the amount expended since the 1st April, 1932, in educational fees on each of the children over 12 years and under 18 years, mentioned in your reply to Question 19 :—

NAME OF CHILD

Amount expended since the 1st April, 1932, in educational fees

(Receipts for school fees should be attached.)

21. State whether the 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 ; (j) National Army ; (k) Defence Forces.
22. (a) Give full particulars of any pension, allowance or gratuity which the deceased held in respect of any wound or injury received in or disease contracted in the services mentioned in your reply to above question.
(b) State clearly the source from which payment of such pension, allowance or gratuity was made.
23. Give particulars of any payments the applicant has received from Army Funds since the death of deceased.
24. State whether any claim has been made or is being made by the applicant under the Army Pensions Acts, 1923 to 1932, in respect of any other person.
25. (a) State whether the applicant was at the date of the death of the deceased wholly dependent on him. If not wholly dependent, state the extent to which the applicant was dependent on him.
(b) State whether the children specified in your answer to Question 19 above were, at the date of the death of deceased, wholly dependent on him. If not wholly dependent on him, state the extent to which they were dependent.
26. Is there any other information which you can give which is material to the applicant's claim?

I declare that :—

(a) I am the applicant mentioned in the foregoing particulars,

(b) the said particulars have been read over by or to me before signing this declaration,

Signature of Applicant............................................................ ........
Address of Applicant............................................................ ........
	............................................................ ........

or (where application is sent in by another person on behalf of applicant) :—

I declare that :—

(a) this application is made by me on behalf of the above-mentioned applicant,

(b) that the foregoing particulars have been read over by or to me before signing this declaration,

Signature of Declarant............................................................ .......
Address............................................................ ...............................
Description............................................................ ..........................
*Signature of Witness............................................................ ............................................................ .........
Address............................................................ ............................................................ ...................................
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 no 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.

A.P. 52.

ARMY PENSIONS ACT, 1932 .

APPLICATION FOR AN ALLOWANCE OR A GRATUITY UNDER SECTION 12 of THE ARMY PENSIONS ACT, 1932 , IN RESPECT OF THE DEATH OF A PERSON BY OR ON BEHALF OF A DEPENDANT (NOT BEING THE WIDOW OR CHILD) OF SUCH PERSON.

INSTRUCTIONS FOR USE OF THIS FORM.

1. In every case the name to be inserted as applicant is that of the person by whom or on whose behalf it is claimed that she or he is entitled to the allowance or gratuity.

2. This application form is to be signed by the applicant, except where the Minister for Defence authorises it to be signed on behalf of the applicant by another person.

3. The attention of the person signing this form is directed to the declaration at the foot hereof to be made by such person.

4. The signature of the person signing this form is to be attested by a witness. (As to who may be a witness, see foot of this form.)

5. In the event of the person making the application being unable to write he or she is to sign by affixing his or her mark and the attesting witness is to insert the name of such person.

Name of Applicant		(To be............................................................ ............................................
		written in		(Surname)
		Block
		Capitals)............................................................ ............................................
			(Mr., Mrs. or Miss) (Christian Names)
Address............................................................ ............................................................ ..........................
Nearest Gárda Síochána Station............................................................ ..............................................
Distance of nearest Railway Station from Residence............................................................ ...............
Distance of nearest Bus route from Residence............................................................ .........................
Whether Railway or Bus is the more economical method of transport between Residence and Dublin............................................................ ............................................................ ....................
Name of Deceased Member............................................................ ...................................................
Late of (Address)	............................................................ ............................................................ .
	............................................................ ............................................................ .

NOTE.—Before answering any of the questions below, the person making the declaration at the foot of this form is to note that the statements made will be checked.

The Army Pensions Act, 1932 , imposes a summary penalty for a false declaration.

If the declarant 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 relationship of applicant to deceased and such of the following particulars as is appropriate :—
(a) If father and over 60 years of age, date of birth (certificate of birth to be attached).
(b) If father and incapacitated by ill-health, nature of such incapacity (medical certificate to be attached).
(c) If a brother under the age of 18 or an unmarried sister under the age of 21, date of birth (certificate of birth to be attached).
(d) If permanently invalided brother or permanently invalided unmarried sister, nature of illness (medical certificate to be attached).
2. State whether the applicant at the date of death of the deceased was wholly dependent on him. If not wholly dependent, state the extent to which the applicant was dependent. The full circumstances as to dependency in either case should be set out in a separate statement if necessary.
3. State whether any claim has been made, or is being made by the applicant in respect of any other member of any of the organisations mentioned in 6 or of the National Army or Defence Forces.
4. (a) When and where did the deceased die, and what was the cause or causes of death ? (Certificate of death to be attached.)
(b) If the deceased died as a result of refusing to take nourishment while detained in prison, or died by violence while a prisoner, give details of the date, place and circumstances.
5. State whether the deceased was married.

6. Give particulars of the service of the deceased in any of the under-mentioned Organisations :—

ORGANISATION

Period of Service

In what capacity he served

In what areas he served

Name of his Commanding Officer

From

(a) Oglaigh na h-Eireann (Irish Republican Army)

(b) Irish Volunteers

(d) Fianna Eireann

(e) Hibernian Rifles

(f) Cumann na mBan

7. (a) When and in what area did the deceased receive the wound or injury or contract the disease which resulted in death ?

(b) Who was the deceased's Commanding Officer at the time ?

7D. Replies to Questions 7D (i) to (v) to be filled in only in case of death due to Disease.

(i) In what way is it claimed that the disease which was the cause of death was connected with the Military Service of the deceased and what are the grounds for the claim ?
(A detailed statement of the facts with dates should be given.)
(ii) Were there any particular conditions affecting the service of the deceased which it is claimed caused the disability (or disabilities) ? Did the deceased suffer from any illness during the period of his service ? If so, give particulars, including any treatment received.
(iii) 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 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 Employers in respect of the three years prior to his joining the particular force.
(iv) 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 any disability referred to in the reply to Question 4 above.
(b) During the period of his Military Service referred to at 6.
(c) During the period since the cessation of his Military Service.
(v) Was the deceased at any time prior to his service referred to at 6 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.

8. Give the names of the hospitals where the deceased was treated for the disability (or disabilities) stated in reply to Question 4 above, and the approximate dates of admissions and discharges, if possible.
9. Did the deceased suffer from the disability (or disabilities) mentioned in above answer to Question 4, or anything like it, prior to Military Service ? If so, give details and dates.
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 ailments for which treatment was provided.
11. What was the nature of the employment of deceased—
(a) before his Military Service referred to at 6.
(b) during the period of such Military Service,
(c) after the cessation of such Military Service ?
12. 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.).
13. Did either the deceased or the applicant receive compensation from the deceased's Employers, or from any person or body in respect of any accident, injury, or disease ? If so, give full particulars and state the amount of such compensation.
14. Give the names and addresses of any Doctors who attended the deceased since the cessation of his Military Service, and particulars of the ailments for which they attended him.
15. 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.
16. 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.
17. Has the applicant 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 or on behalf of the person alleged to be responsible for the act which caused such disability ;
(d) from any other source ?
If so, give full particulars.
18. Give the name of deceased's National Health Approved Society, and (if possible) his membership number.
19. 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 ?
20. Did the applicant, or did the deceased, make any claim under the Army Pensions Acts, 1923 and 1927, in respect of the wound or disease which caused the death of the deceased ? If so, what was the result of such claim ?
21. Give particulars of any pension or gratuity awarded to the deceased under the Army Pensions Acts, 1923 and 1927, in respect of a wound or injury received or disease contracted in the course of duty with the Irish Volunteers, Irish Citizen Army, 1916, National Army or Defence Forces.
22. 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 ; (j) National Army ; (k) Defence Forces.
23. (a) Give full particulars of any pension, allowance or gratuity which the deceased held in respect of any wound or injury received in or disease contracted in the services mentioned in your reply to above questions.
(b) State clearly the source from which payment of such pension, allowance or gratuity was made.
24. Give particulars of any payments the applicant has received from Army Funds since the death of deceased.

I declare that :—

(a) I am the applicant mentioned in the foregoing particulars,

(b) the said particulars have been read over by or to me before signing this declaration.

Signatre of Applicant............................................................ ........................

Address of Applicant............................................................ ..........................

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

or (where application is sent in by another person on behalf of applicant) :—

I declare that :—

(a) this application is made by me on behalf of the above-mentioned applicant,

(b) that the foregoing particulars have been read over by or to me before signing this declaration,

				Signature of Declarant............................................................ ........
Address					............................................................ ...............................
Description						............................................................ ..........................
* Signature of Witness			............................................................ ............................................................
Address		............................................................ ............................................................ ..............................
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.