CO129-428 - Public Offices - 1915 — Page 53

Here insert

name,

address, and description

of claimant.

C

of

I,

in the

of

See paragraph 2 of the accompanying In- structions.

do solemnly and sincerely declare that:

I. I was born on

-

at

51280

feet & NCV151

51

See paragraph 5 of the accompanying In- structions.

See paragraph 5 of the accompanying In- structions.

2. I was a passenger on board the steamship

the time when she was attacked and sunk by a submarine.

at

123

3. The property specified in the Schedule hereto was on board the said ship when she was sunk, and was lost with her.

4. I was the absolute owner of the said property at the time of its loss.

5. The said property was at the time of its loss of the value set out in the Schedule hereto, amounting in all to

2. I have not,

nor has anyone on my behalf, received any payment in respect thereof.

And I make this solemn Declaration conscientiously believing the same to be true and by virtue of the provisions of "The Statutory Declarations Act, 1835."

Declared at

the

day of

191

Before me,

[1043]

SCHEDULE.

Particulars of Property.

Value of Property

at the Time of Loss.

[P.T.O.