86

THE NEW ZEALAND GAZETTE.

Signature of Applicant
Date ........................................................
(1) Christian and Surname at full length.
(2) Place of residence or business, and post town.
(3) In words at full length.

(E.)
ABSTRACT of INSTRUMENT requiring to be STAMPED
AFTER EXECUTION.

Date of Application .....................................186.
Signature of Applicant....................................
Amount of duty payable £ : :
Amount of fine payable £ : :
....................................................Commissioner.

(F.)
AFFIDAVIT or AFFIRMATION to be made to obtain
ALLOWANCE of SPOILED STAMPS.

New Zealand,?
To wit.
In the matter of the application of
for allowance of Spoiled Stamps.

"ON the day of 18 , maketh
Where affirmation oath and saith, that the several Stamps
made this form can hereinafter specified and described, that is to
be so altered. say,—

are the property of this Deponent, and were purchased by him,
or for his use, and that he has paid or now stands indebted for
and is really and truly liable to pay the full amount, or value
Parchment or paper thereof. And with regard to such of the skins,
not written upon. sheets, or pieces of parchment or paper on
which the said Stamps are affixed or impressed as are not written
upon, this Deponent saith that the same have been inadvertently said
and undesignedly spoiled and rendered unfit for use.
Instruments exe- And with regard to
cuted. bearing date the
and which appears to have been
signed by the duplicate (or instrument in lieu) of which
is now produced and exhibited, this Deponent saith that the
Here state cause for same was spoiled in consequence of
rendering the same and that since the same was so signed no
useless. addition or other alteration whatever has been
made therein or thereto, but that the same is now in the same
state and condition as when the same was so signed, and that
the same was bond fide prepared and signed for the purpose of
carrying into effect the transaction appearing upon the face thereof
between the parties, and upon the terms and conditions therein
set forth, and that the same was so signed within three calendar
Instruments written months preceding the date hereof. And
but not signed. with regard to such other of the skins, sheets,
or pieces of parchment or paper on which the said Stamps
are affixed or impressed as are written upon, this Deponent saith
that the same have been inadvertently and undesignedly spoiled,
or are become useless, and that the writing on any of the said
skins, sheets, or pieces of parchment or paper hath not been
signed by any party, or otherwise completed as a legal instru-
ment, and hath not had any operation or effect whatsoever.
Bills of Exchange and And with regard to the several Bills of
Promissory Notes. Exchange and Promissory Notes written on
the paper, whereon the said Stamps are affixed or impressed, the
same have been inadvertently obliterated or spoiled, or are unfit
for the purpose intended, by reason of a mistake therein (or of
their being written on wrong Stamps, or are become useless
through accidental and unforeseen circumstances), and that,
although the said Bills of Exchange and Promissory Notes are
signed by or on behalf of this Deponent [affirmant] as the
drawer thereof, the same or any of them have not been delivered
out of hands to the payees therein named, or any person
behalf, nor been deposited with any person as a
security for the payment of money, nor been in any way
negotiated, issued, or put in circulation, nor been made use of
in any other manner whatsoever, and that the said Bills of
Exchange have not been accepted by the drawees, or tendered
for such acceptance; and that such of the said Bills and Notes
as are not dated, were signed within the period of three calendar
months preceding the date hereof. And this Deponent further
saith that he hath not in any way been reimbursed or paid the
value of the said Stamps, or any part thereof, by any other
person or persons, and that, if the value shall be allowed by the
Commissioner of Stamp Duties, he will not ask or receive any
compensation for the same or any part thereof, from any other
person or persons, or charge the same, or any part thereof, in
account or otherwise, to any other person or persons, either
generally or particularly, so as to be again paid or compensated
for the same or any part thereof, directly or indirectly, in any
manner whatsoever. And this Deponent further saith that the
application made by him for an allowance for the value of the
said Stamps, is without any fraudulent intention or collusion
whatsoever.

Sworn by the Deponent the day first
above mentioned, before me,

(G.)
RECEIPT for SPOILED STAMPS.
No. ................

Stamp Office, ............................................, 186 .

I CERTIFY that of in the Province of
has this day deposited at this Office the Stamp particularized
on the back hereof for allowance, accompanied with an Affidavit
duly sworn, setting forth how the same w rendered useless.

Stamp Office Clerk.

If the allowance is granted, this receipt must be exchanged
for an Allowance Order, within one month from the date hereof.
This receipt is not transferable.

(H.)
No. ................

ORDER for ALLOWANCE in LIEU OF SPOILED STAMPS.

Date when Affidavit IN consideration of the circumstances set
left at the Stamp forth, and of the surrender of the Spoiled
Office: Stamps specified in the Affidavit of
of in the Province of
186 , I
hereby authorize and allow the issue to the
of Duties' Stamps of the total value of

For the Commissioner of Stamps.

Stamp Office,..........................................., 186 .

The person to whom this Order is issued must produce the
same at the office whence it was issued, and must claim the
Stamps to which he is hereby entitled within one calendar
month from the date hereof, or the Stamps left for allowance
will be forfeited. The Stamps required to be issued in lieu of
those spoiled must be particularized on the back hereof.
The allowance (if any) made by way of commission at the
time of purchase of the Stamps spoiled, must be refunded
before this Order can be made available.

This Order is not transferable.

(I.)
FORM of AFFIDAVIT, to be sworn to by Executor or
Administrator, and to be lodged with any Probate
or Letters of Administration, for the purpose of
having such Probate or Letters of Administration
stamped under "The Stamp Duties Act, 1866."