S.I. No. 181/1933 - Army Pensions (Forms of Application) Regulations, 1933.

1. State relationship of applicant to deceased and such of the following particulars as is appropriate :—

(a) If father and over 60 years of age, date of birth (certificate of birth to be attached).

(b) If father and incapacitated by ill-health, nature of such incapacity (medical certificate to be attached).

(c) If a brother under the age of 18 or an unmarried sister under the age of 21, date of birth (certificate of birth to be attached).

(d) If permanently invalided brother or permanently invalided unmarried sister, nature of illness (medical certificate to be attached).

2. State whether the applicant at the date of death of the deceased was wholly dependent on him. If not wholly dependent, state the extent to which the applicant was dependent. The full circumstances as to dependency in either case should be set out in a separate statement if necessary.

3. State whether any claim has been made, or is being made by the applicant in respect of any other member of any of the organisations mentioned in 6 or of the National Army or Defence Forces.

3D. Replies to questions 3D (i) to (v) to be filled in

only

by applicants

in

r espect of

Disease

(i) In what way is it claimed that applicant's disease is connected with his Military Service, and what are the grounds for the claim ?

(A detailed statement of the facts with dates should be given.)

(ii) Were there any particular conditions affecting applicant's service which it is claimed caused the disability or disabilities ? Did the applicant suffer from any illness during the period of his service ? If so, give particulars, including any treatment received.

(iii) Give particulars of the applicant's health for the 3 years prior to joining the particular Force in which it is claimed he incurred the disability (or disabilities). If possible, certificates should be furnished :—

(a) from his doctor, and

(b) from his approved Society for the 3 years prior to joining the particular Force, or if he was not an insured person, certificates should be furnished by the Medical Practitioner who ordinarily attended him during these 3 years. A statement will also be required from his Employer or Employers in respect of the 3 years prior to his joining the particular Force.

(iv) Give the names and addresses of the applicant's Employers :—

(a) During the 3 years prior to joining the particular Military Force in which it is claimed he contracted any disability referred to in the reply to Question 2 above.

(b) During the period of his Military Service referred to at 1.

(c) During the period since the cessation of his Military Service.

(v) Was the applicant at any time prior to his service referred to at 1, a candidate for any appointment which necessitated a medical examination ? If so, state the nature of the appointment and the result of the medical examination.

4. (a) When and where did the deceased die, and what was the cause or causes of death ? (Certificate of death to be attached.)

(b) If the deceased died as a result of refusing to take nourishment while detained in prison, or died by violence while a prisoner, give details of the date, place and circumstances.

4D. Replies to Questions 4D. (i) to (v) to be filled in

only

in case of

death

due to

Disease

.

i) In what way is it claimed that the disease which was the cause of death was connected with the Military Service of the deceased and what are the grounds for the claim ?

(A detailed statement of the facts with dates should be given.)

(ii) Were there any particular conditions affecting the service of the deceased which it is claimed caused the disability (or disabilities) ? Did the deceased suffer from any illness during the period of his service ? If so, give particulars, including any treatment received.

(iii) Give particulars of the health of the deceased for the three years prior to joining the particular force in which it is claimed he incurred the disability (or disabilities) which caused his death. If possible certificates should be furnished :—

(a) from his doctor, and

(b) from his approved Society for the three years prior to joining the particular force, or if he was not an insured person, certificates should be furnished by the Medical Practitioner who ordinarily attended him during those three years. A statement will also be required from his Employers in respect of the three years prior to his joining the particular force.

(iv) Give the names and addresses of his Employers :—

(a) During the three years prior to joining the particular Military Force in which it is claimed he contracted any disability referred to in the reply to Question 2 above.

(b) During the period of his Military Service referred to at 3.

(c) During the period since the cessation of his Military Service.

(v) Was the deceased at any time prior to his service referred to at 3 a candidate for any appointment which necessitated a medical examination ? If so, state the nature of the appointment and the result of the medical examination.

5. State whether the deceased was married.

6. Give particulars of the service of the deceased in any of the under-mentioned Organisations :—

ORGANISATION

Period of Service

In what capacity he served

In what areas he served

Name of his Commanding Officer

From

To

(a) Oglaigh na h-Eireann (Irish Republican Army)

(b) Irish Volunteers

(c) Irish Citizen Army

(d) Fianna Eireann

(e) Hibernian Rifles

(f) Cumann na mBan

7. (

a

) When and in what area did the deceased receive the wound or injury or contract the disease which resulted in death ?

(

b

) Who was the deceased's Commanding Officer at the time ?

(

c

) Give the names of any persons who can corroborate your answer to (

a

) above.

7D. Replies to Questions 7D (i) to (v) to be filled in

only

in case of death due to

Disease

.

(i) In what way is it claimed that the disease which was the cause of death was connected with the Military Service of the deceased and what are the grounds for the claim ?

(A detailed statement of the facts with dates should be given.)

(ii) Were there any particular conditions affecting the service of the deceased which it is claimed caused the disability (or disabilities) ? Did the deceased suffer from any illness during the period of his service ? If so, give particulars, including any treatment received.

(iii) Give particulars of the health of the deceased for the three years prior to joining the particular force in which it is claimed he incurred the disability (or disabilities) which caused his death. If possible certificates should be furnished :—

(a) from his doctor, and

(b) from his approved Society for the three years prior to joining the particular force, or if he was not an insured person, certificates should be furnished by the Medical Practitioner who ordinarily attended him during those three years. A statement will also be required from his Employers in respect of the three years prior to his joining the particular force.

(iv) Give the names and addresses of his Employers :—

(a) During the three years prior to joining the particular Military Force in which it is claimed he contracted any disability referred to in the reply to Question 4 above.

(b) During the period of his Military Service referred to at 6.

(c) During the period since the cessation of his Military Service.

(v) Was the deceased at any time prior to his service referred to at 6 a candidate for any appointment which necessitated a medical examination ? If so, state the nature of the appointment and the result of the medical examination.

8. Give the names of the hospitals where the deceased was treated for the disability (or disabilities) stated in reply to Question 4 above, and the approximate dates of admissions and discharges, if possible.

9. Did the deceased suffer from the disability (or disabilities) mentioned in above answer to Question 4, or anything like it, prior to Military Service ? If so, give details and dates.

10. Give the names of any hospital or hospitals, in which the deceased received treatment as an in-patient or an out-patient, prior to the period of his service, and the nature of the ailments for which treatment was provided.

11. What was the nature of the employment of deceased—

(a) before his Military Service referred to at 6.

(b) during the period of such Military Service,

(c) after the cessation of such Military Service ?

12. Give particulars of any period, or periods of unemployment since the cessation of the Military Service of the deceased, and the cause of it (e.g., trade depression, ill-health, etc.).

13. Did either the deceased or the applicant receive compensation from the deceased's Employers, or from any person or body in respect of any accident, injury, or disease ? If so, give full particulars and state the amount of such compensation.

14. Give the names and addresses of any Doctors who attended the deceased since the cessation of his Military Service, and particulars of the ailments for which they attended him.

15. If the deceased was treated at a hospital (either as an in-patient or an out-patient) since the cessation of his Military Service, give the name of the hospital, or hospitals, dates of admission, or commencement of treatment, and the nature of the ailment for which treated.

16. Give particulars of the health of deceased since the cessation of his Military Service. These should be supported by :—

(a) medical certificates from any civilian doctors who attended him, and reports from non-military hospitals which deceased attended.

(b) certificates from deceased's Employers as to health and time lost.

17. Has the applicant received, or did the deceased receive, in respect of the disability, or disabilities, which caused his death any payment :—

(a) on a decree under the Criminal Injuries (Ireland) Acts, 1919 and 1920 ;

(b) on an award made by the Personal Injuries Committee ;

(c) from or on behalf of the person alleged to be responsible for the act which caused such disability ;

(d) from any other source ?

If so, give full particulars.

18. Give the name of deceased's National Health Approved Society, and (if possible) his membership number.

19. Did the deceased make a claim for a certificate of service under the

Military Service Pensions Act, 1924

? If so, what was the result of his claim ?

20. Did the applicant, or did the deceased, make any claim under the Army Pensions Acts, 1923 and 1927, in respect of the wound or disease which caused the death of the deceased ? If so, what was the result of such claim ?

21. Give particulars of any pension or gratuity awarded to the deceased under the Army Pensions Acts, 1923 and 1927, in respect of a wound or injury received or disease contracted in the course of duty with the Irish Volunteers, Irish Citizen Army, 1916, National Army or Defence Forces.

22. State whether deceased was at any time in receipt of a pension, allowance or gratuity, in respect of injuries received or disability incurred in the course of service with any of the following Military or Police Forces—(a) British ; (b) Australian ; (c) New Zealand ; ( d ) South African (e) Canadian ( f ) American (U.S.A.) ; (g) Royal Irish Constabulary; (h) Dublin Metropolitan Police; (i) Gárda Síochána ; (j) National Army ; (k) Defence Forces.

23. (a) Give full particulars of any pension, allowance or gratuity which the deceased held in respect of any wound or injury received in or disease contracted in the services mentioned in your reply to above questions.

(b) State clearly the source from which payment of such pension, allowance or gratuity was made.

24. Give particulars of any payments the applicant has received from Army Funds since the death of deceased.

I declare that :—

(

a

) I am the applicant mentioned in the foregoing particulars,

(

b

) the said particulars have been read over by

or

to me before signing this declaration.

(

c

) the said particulars are true to the best of my knowledge, information or belief.

Signatre of Applicant............................................................ ........................

Address of Applicant............................................................ ..........................

............................................................ ..........................

or (where application is sent in by another person on behalf of applicant) :—

I declare that :—

(

a

) this application is made by me on behalf of the above-mentioned applicant,

(

b

) that the foregoing particulars have been read over by

or

to me before signing this declaration,

(

c

) that the said particulars are true to the best of my knowledge, information and belief.

Signature of Declarant............................................................ ........

Address

............................................................ ...............................

Description

............................................................ ..........................

* Signature of Witness

............................................................ ............................................................

Address

............................................................ ............................................................ ..............................

Qualification of Witness

............................................................ .....................................................

Date

............................................................ .............

* To be signed by one of the following :—

A Commissioned Officer serving in the Defence Forces.

A Permanent Civil Servant (active or retired) whose salary is or was not less than £200, and on a scale rising to not less than £300.

A District Justice.

A Peace Commissioner.

A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.

A Minister of Religion (denomination to be stated).

A Registered Physician or Surgeon.

Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.

A member of the Gárda Síochána.

A Postmaster or Postmistress in actual charge of a Post Office.

Head Teachers of Secondary or National Schools.

A Secretary of a Registered Friendly Society.

25. (a) State whether the applicant was at the date of the death of the deceased wholly dependent on him. If not wholly dependent, state the extent to which the applicant was dependent on him.

(b) State whether the children specified in your answer to Question 19 above were, at the date of the death of deceased, wholly dependent on him. If not wholly dependent on him, state the extent to which they were dependent.

26. Is there any other information which you can give which is material to the applicant's claim?

I declare that :—

(

a

) I am the applicant mentioned in the foregoing particulars,

(

b

) the said particulars have been read over by

or

to me before signing this declaration,

(

c

) the said particulars are true to the best of my knowledge, information and belief.

Signature of Applicant............................................................ ........

Address of Applicant............................................................ ........

............................................................ ........

or (where application is sent in by another person on behalf of applicant) :—

I declare that :—

(

a

) this application is made by me on behalf of the above-mentioned applicant,

(

b

) that the foregoing particulars have been read over by

or

to me before signing this declaration,

(

c

) that the said particulars are true to the best of my knowledge, information and belief.

Signature of Declarant............................................................ .......

Address............................................................ ...............................

Description............................................................ ..........................

*Signature of Witness............................................................ ............................................................ .........

Address............................................................ ............................................................ ...................................

Qualification of Witness............................................................ ............................................................ ..........

Date............................................................ ....................

*To be signed by one of the following :—

A Commissioned Officer serving in the Defence Forces.

A Permanent Civil Servant (active or retired) whose salary is or was no less than £200, and on a scale rising to not less than £300.

A District Justice.

A Peace Commissioner.

A Barrister-at-Law, a Solicitor or a Commissioner for Oaths.

A Minister of Religion (denomination to be stated).

A Registered Physician or Surgeon.

Managers, Secretaries, Chief Cashiers, and Accountants of Banks and Officials in charge of Branch Banks.

A member of the Gárda Síochána.

A Postmaster or Postmistress in actual charge of a Post Office.

Head Teachers of Secondary or National Schools.

A Secretary of a Registered Friendly Society.

A.P. 52.

ARMY PENSIONS ACT, 1932

.

APPLICATION FOR AN ALLOWANCE OR A GRATUITY UNDER

SECTION 12

of THE

ARMY PENSIONS ACT, 1932

, IN RESPECT OF THE DEATH OF A PERSON BY OR ON BEHALF OF A DEPENDANT (NOT BEING THE WIDOW OR CHILD) OF SUCH PERSON.

INSTRUCTIONS FOR USE OF THIS FORM.

STATUTORY RULES AND ORDERS. 1933. No. 181.

ARMY PENSIONS (FORMS OF APPLICATION) REGULATIONS, 1933.

WHEREAS by virtue of

Section 20

of the

Army Pensions Act, 1932

(No. 24 of 1932), every application for the grant of a pension, allowance, or gratuity under Part II of the said Act is required to be made to the Minister for Defence in the prescribed form and to contain the prescribed particulars, and by virtue of the said section the Minister for Defence is empowered by order to make regulations prescribing the said form and particulars

NOW, I, FRANK AIKEN, Minister for Defence, in exercise of the powers conferred on me by virtue of

Section 20

of the

Army Pensions Act, 1932

(No. 24 of 1932), and of every and any other power me in this behalf enabling, do hereby order and make the following regulations, that is to say :—