446

THE NEW ZEALAND GAZETTE. [No. 33

DECLARATION.
I, , do hereby declare that the above statement is
true and accurate in all the particulars stated by me, accord-
ing to the best of my judgment and belief, and that I have
therein set forth all the particulars respecting which I am able
to furnish information.
Dated this day of , 18 . Signature :

PERSONAL PROPERTY STATEMENT.
Form No. 3. No. of Assessment:
PROPERTY ASSESSMENT for the Year ending 31st March, 1881.
Property assessment district :
Assessor's division :
Name: [Name must be written in full.]
Occupation :
Address :
In pursuance of "The Property Assessment Act, 1879," you
are hereby required to fill up such of the following statements
in this return as are applicable to your particular case, and cause
the same to be returned to the Deputy Commissioner of your
district at , on or before the day of
next, in default of which you will be liable to a penalty of
£100, and to be assessed and charged treble duty.
Given under my hand this day of , 18 . Assessor.
Address :
NOTE.—At your convenience, your statement may be sent free by post
to the Deputy Commissioner as above, or you may deliver it to me. State-
ments may be sent in at any time not later than the date above specified.

Statement of the Description, Situation, and Value of the
Personal Property of every kind belonging to me, the above-
named , and of all Mortgages, Encumbrances, or
Charges thereon, or which may be owing by or payable to me
in any manner, and of all Debts owing by me for which I
claim a deduction.

Horses, cattle, sheep, and other live stock £
Produce... ... ... ... £
Merchandise ... ... ... ... £
Stock-in-trade ... ... ... ... £
Furniture and household goods, including
jewellery, plate, works of art, books, and all
other personal property whatsoever not other-
wise described ... ... ... ... £
Money owing to me secured on mortgage ... ... ... £
Money owing to me secured on bills of sale or
other instrument of a like nature ... ... ... £
Other debts owing to me ... ... ... ... £

Total amount of debts for which a deduc-
tion is claimed :-
Due by me on bills of sale or other
instrument of a like nature ... ... ...
Other debts ... ... ... ...
Taxable value of personal property ... ... ... £

SCHEDULE I.—PARTICULARS OF MORTGAGES OR BILLS OF
SALE SECURING SUMS DUE TO ME.
Name, Occupation, and Description of Property
Address in full of
Debtor.
Mortgage,
Bill of Sale, or other
Security.
Amount Amount
Secured. Owing.
£
£

SCHEDULE II.—PARTICULARS OF MORTGAGES OR BILLS OF
SALE GIVEN BY ME TO SECURE SUMS DUE TO CREDITORS.
Name, Occupation, and Address in full of
Creditor.
Description of Property covered by Mortgage,
Bill of Sale, or other Security.
Amount Amount
Secured. Owing.
£
£

SCHEDULE III.—NAME OF OWNER, AND DESCRIPTION OF LAND
IN MY OCCUPATION.
Surname.
Christian Name.
Occupation.
Address.
Borough or Road District.
No. of Section or Allotment.
No. or Name of Block or Survey
District.
Area.
Annual Rent.
Annual Value at which Property
is Assessed for Purposes of
Local Taxation.
Date and Tenure of Lease.
Value of Tenant's Interest.

DECLARATION.
I, , do hereby declare that the above statement is true
and accurate in all the particulars stated by me, according to
the best of my judgment and belief, and that I have therein set
forth all the particulars respecting which I am able to furnish
information
Dated this day of , 18 . Signature :

FOURTH SCHEDULE.
COMPANY'S STATEMENT.
Form No. 5.
Statement of the [corporate name] Company, by
the Public Officer thereof, for the purposes of "The
Property Assessment Act, 1879."
PROPERTY ASSESSMENT for the Year ending 31st March, 1881.
In pursuance of "The Property Assessment Act, 1879," you
are hereby required to fill up such of the following statements
as are applicable to your particular Company, and to cause the
same to be returned to my office on or before the 30th day
of June next; in default of which you will be liable to the
penalty prescribed by the Act.
You are also required to furnish with this Schedule a copy
of the latest annual balance-sheet of the Company.
If the Company is possessed of any freehold land, the Public Officer
will also fill in and return Form No. 2. If the Company is the tenant
of any land, the Public Officer will also fill in and return Form No. 3.
Dated this day of 18 . Commissioner.

Name and address of the Company :
Name and address of the Public Officer :
Place of principal operations of the Company :
Total value of assets of Company, £
The assets of the Company shall be taken to be the marketable value
of the property of the Company, and shall not include unpaid-up
capital.
Total liabilities of Company, £
In estimating the liabilities of a company, the amounts received in
respect of shares issued shall not be reckoned as liabilities.
Market value of shares in the said Company at this date
shares at per share, £ .