[ See Chapter XXI, para 529-A, rule 8 ]

( To be printed on foolscap quarto )

Half-yearly declaration of female pensioners whose pensions are terminable on their marriage.

(This certificate is to be attached to the pension bills for December and June).

Pension Payment Order No. _____________________

I, hereby, declare that I am not married and that I have not been married during the past half-year



of the late _________________________________________________________


Dated____________19 .

To be signed by two responsible Officers or well-known persons.

We certify to the best our knowledge and belief that the above declaration is correct.





Dated______19 .