THE NEW ZEALAND GAZETTE. 65

Instructions to Proposer.
Your address should be fully
stated on the line marked
(c)

If you wish to purchase an im-
mediate Annuity, insert the
amount of such Annuity in
the space under the letter (d)

If you wish to purchase a de-
ferred Annuity, insert the
amount of such Annuity in
the space under the letter (e),
and the number of the years
which are to expire before
the Annuity commences in the
space under the letter (f),
and write the words "a single
payment," or the words "an-
nual payments," in the space
under the letter (g), according
as you wish to purchase the
Annuity by a single payment
or by annual payments. If
you wish the purchase money
to be returnable, draw a line
with ink through the words
"not in any event"

If you wish to purchase the
Annuity for your own benefit
and on your own life, write
the word "myself" on the
line marked (k)

But if you wish to purchase the
Annuity for the benefit and
on the life of another person,
state the full Christian Names
and Surname of that person
on the line marked (l)

State his or her trade, calling, )
or occupation (if any) on the
line marked (m)

And state his or her residence
fully on the lines marked (n)

[If the Annuity is to depend on
your own life, it will of course
be unnecessary for you to re-
peat the statement of your
name, occupation, and resi-
dence.]

If the Annuity is to depend on
your own life, the place at
and the date on which you
were born must be inserted
at (o) and (p); but if the
Annuity is to depend on the
life of another person, then
the place and date of birth of
that person must be stated
...

Form of Declaration.

WHEN this Proposal Form has been filled up, the
following Declaration must be signed by the Pro-
poser in the presence of a Postmaster or other
Officer duly appointed for the purpose.

I do hereby declare that the foregoing statements made by
me are true, to the best of my knowledge and belief. I agree
that the foregoing statements shall be the basis of the proposed
contract; and that if it shall hereafter appear that I have wilfully
made any untrue statement, then all the premiums which shall
have been paid under the said contract shall be forfeited, and
the contract rendered absolutely null and void.

(Signature of Proposer.)

Statement by Postmaster or other Officer.
Postmaster's Certificate.

I certify that I read over and explained the above declaration

Statement to be made by
Proposer.

(c) desires to purchase
(d) An Annuity of £ to
commence immediately, and
to be payable half-yearly.

An Annuity of £ (e) to
commence after the expi-
ration of (f) years
from the date of purchase
and to be purchased (g)
by on the con-
dition that the purchase
money shall not in any
event be returnable.

The Annuity is to be pur-
chased for the benefit of
and is to depend on the
life of (k)

(l)

(m) residing at

(n)

I declare that the person
for whose benefit and on
whose life the Annuity is
to be purchased was born
at
(o)
on the
(p) day of in the year and
that the said person will
be years of age
next birthday.

to the Proposer in this case, and that the Proposer's signature
was affixed in my presence.

day of 18 (Signature of Officer.)

Proposal to be forwarded to Commissioner. Untrue statements
render the contract void.

18. The proposal thus duly signed by the Proposer
    shall be forwarded to the office of the Government
    Annuities Commissioner by the Postmaster or other
    officer with whom it is deposited; and if the said
    Commissioner, after examination of the evidence of
    age and inquiry of the persons to whom the Proposer
    refers him, shall think fit to enter into a contract
    with the Proposer in the manner proposed, the pro-
    posal shall be taken to be the basis of such contract;
    and if the Proposer shall afterwards be proved to
    have wilfully made any untrue statement of the age
    of the person upon whose life and for whose benefit
    the Annuity is granted, then any purchase money or
    instalments of purchase money which shall have been
    paid under the contract shall be forfeited, and the
    contract rendered absolutely null and void. The
    said Commissioner may decline or refuse to contract
    for any Annuity in any one case where there shall
    be, in the opinion of the said Commissioner, sufficient
    grounds for refusing or declining so to do.

Annuity Tables.

19. If the Government Annuities Commissioner
    shall think fit to enter into a contract for the grant
    of an Annuity on the life of any person, he shall
    require the purchaser to pay such sum or sums of
    purchase money, according to the age and sex of the
    person on whose life the Annuity is to depend, and
    the period at which the Annuity is to commence, as
    shall be fixed by the Tables framed under the
    authority of "The Government Annuities Act, 1869."

Form of Contract.

20. The contract shall be in the following form,
    and shall specify,—

(1.) The name of the person on whose life the
Annuity is to depend;
(2.) The amount of the Annuity;
(3.) The amount of the purchase money, if it be
payable in one sum, or of an instalment of
the purchase money, if it be payable by in-
stalments;
(4.) The periods at which such instalments be-
come due and payable;
(5.) The period at which the Annuity is to
commence; and
(6.) The conditions under which the purchase
money or any instalments thereof will be
forfeited, and the contract rendered null and
void.

FORM OF CONTRACT for the Grant of an Immediate or
Deferred Annuity when the Purchase Money shall
be paid in one Sum, and when the Condition of Pur-
chase shall be that no part of the Purchase Money
shall in any event be returnable.

WHEREAS under the provisions of "The Government Annuities
Act, 1869," I, the undersigned, now holding the office of Go-
vernment Annuities Commissioner, am authorized to execute
contracts for grant of Annuities: And whereas of
has contracted with the said Commissioner for the purchase of
£ to be paid to by equal
half-yearly payments on and has deposited with me, the
said Commissioner, a proposal, and declaration dated the
day of
signed by him, as the basis of the contract for the purchase of
such in which proposal it is stated, amongst other
things, that the age of is not less than years:
And whereas has paid to me, the said Commissioner,
the sum of £ as the consideration for the said
Now it is hereby declared that the Government Annuities Com-
missioner shall, pursuant to the said Act, be subject and liable
to pay to the said the sum of £ on
without any deduction or abatement whatsoever.