Particulars of wife
Wife's full clan or other forenames
Date of your marriage
Is your wife living with you? (Yes or No)
Place of your marriage (in full).
If you have no wife please give separate details of any child under the age of 16 years, or under 19 years if he or she is receiving full-time education.
The Personal Injuries (Civilians) Scheme states that a claim to pension must be made within three months of the date of the qualifying injury. In exceptional circumstances this time limit can be waived. Please, therefore, state your reasons for not claiming earlier.
I
WAS
COMPLETELY
UN AWARE
THAT
Σ
MIGHT
BE
ENTITLED
то
ANY
KIND
Of
PENSION
AS
A
civilian
IN FERNEE
DECLARATION
(WARNING – TO GIVE FALSE INFORMATION MAY RESULT IN PROSECUTION)
I DECLARE that to the best of my knowledge and belief the information given is true and complete. I claim pension accordingly.
I hereby authorise the doctors and hospitals named to make my medical records available to the Department to be copied for confidential retention and use for war pensions purposes.
Usual signature
Lea Mathias
Tha
(4)
Date.
13
Ok
MARCt.