Form Of Claim For Senior Citizens (Page 4 of 4) in pdf

Form Of Claim For Senior Citizens Page 4

WARNING

Any person, who for the purpose of obtaining or continuing a Senior Citizens’ Pension, either for

himself or for any other person, or for the purpose of obtaining or continuing a Senior Citizens’

Pension for himself or any other person at a higher rate than that appropriate to the case; knowingly

makes any false statement or false representation, and any person who knowingly obtains payment

of, or continues to receive a Senior Citizens’ Pension which he is disqualified from receiving or which

for any reason is not payable to him, is liable on summary conviction to imprisonment.

DECLARATION

I declare that all the statements in this form are true to the best of my knowledge and belief, and that I am

not, so far as I know, disqualified from receiving a Pension for any of the reasons stated on this form.

Applicant’s signature or (mark) ………………………………………….

Witness to declaration ……………………………………...

Address ……………………………………………………..

……………………………………………………….………

Telephone Number ………………………………………….

Occupation …………………………….…………………….

Date ………………………………………………………….

. – AG 169 – 10,000 - /16

G.P., T

./T

Form Of Claim For Senior Citizens Page 4