DEPARTMENT OF SOCIAL SECURITY
Pension for Disablement
Civilian or Civil Defence Volunteer
Please read these notes:
THAT WINIC)
ZA
Reference ...F....1.549.7
This form is for claiming a pension, including a dependency allowance for family, for disablement directly attributable to a war injury or a war service injury.
A disablement pensioner may be awarded a dependency allowance for his wife, or where there is no wife for a child under the age of 16 years, or 19 years if he or she is receiving full-time education.
An allowance may not be payable if your wife or child is not living with you.
Particulars of claimant
Your full names
а
As far as you can, write a definite reply to each question which you are asked to answer. If you do not know the reply write "Do not know”.
If you need advice or help in filling up the form the local office of the Department of Health and Social Security will be glad to help you. You can get the address at the Post Office.
When you have filled up the form you must sign the Declaration on page 4. Complete and despatch this form as soon as possible: date of payment depends on date of claim.
Details
in Jap Assts
BROH.. Both Names. Confirmed ве 1.27.3.90 22/3/20 MATH AS
(Surname first in BLOCK CAPITALS)
Your full address.......PENRITH
DOROTHEA
EVELYNE
DOWN RD TAVISTOCK
DEVON
PLIG GAS
Your date of birth.
14 5-
........Decorations (if any)...
Your place of birth...........
HOVE
SUSSER
f
Please state whether you are single, married or widowed?.
(If married or have children. please give details on page 4) If you are a married woman, date of marriage.
Maiden sumame
BAIRD
MARRIED.
11-
9
1937
Your national insurance number
Letters
Figures
Letter
C
NA 0567/88
If you are receiving a national insurance retirement pension please give your pension number
a
Have you ever received, or are you receiving, an award made under the Industrial Injuries Acts? (YES or NO).......
Particulars of any service in HM Forces
Have you served in the Navy, Army or Air Force at any time? (YES or NO)..
If YES, please state:
Unit or
Ship
Date of enlistment..
MPC3
2881 R669
NR
No
No
& SOCIAL SECURITY
Rank or Rating
DEPT OF HEALTH
24
Official
27 MAR 1990.... Number. Date discharge
of
(1)
please turn over