Total Amount Received on Account of— 
Sickness Benefits 
Annuities Commencing 
Yeal* Ending 
Total 
Funds at 
end 
of Year. 
Amount 
Received 
as 
Interest. 
Ceasing 
at Age . 
to 
.3 o 
CO to 
§◄ 
Ceasing 
at Age . 
Through 
out Life. 
Sums at 
Death. 
At Age . j 
At Age . ' 
l 
At Age . J 
Endow 
ments. 
Other 
Receipts 
(to be 
specified). 
£ 
31st Dec., 18 
„ 18 
„ 18 
„ 18 
„ 13 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
Total - 
to Total Amount Paid on Account of Sickness Benefits. 
Ceasing at Age 
Ceasing at Age 
Ceasing at Age 
Throughout Life. 
Yeal* Ending 
| Full Pay. 
o 
lib 
3 ©•“< 
[=<P3 
Permanent 
Reduced 
Pay 
(if any). 
| Full Pay. | 
Reduced 
Pay. 
O • 
P 5 d 
Permanent 
Reduced 
Pay 
(if any). 
& 
P-i 
Reduced 
Pay. 
Further 
Reduced 
Pay. 
+3_ 
§.ej?g 
S a r “ l 
B 
Ah 
Full Pay. i 
4> . 
Sb 
Further 
Reduced 
Pay. 
Permanent 
Reduced 
Pay 
(if any). 
31st December, 18 - 
„ „ 18 .... 
„ „ 18 .... 
„ „ 18 .... 
„ „ 18 .... 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
£ 
Total - 
1 
VALUATION. 291