Jan. 3.] THE NEW ZEALAND GAZETTE. 21

tains a true and complete statement of accounts between
the said and the said debtor.
3. That the said (6) has not received or been pro-
mised, nor hath any person to my knowledge or belief, for
the use or on account of the said (6), had or received
or been promised, any satisfaction, payment, or security
whatsoever for the said sum or any part thereof.
(7) [If any securities are held, allegation may be in follow-
ing form, as the case requires:] That the only securities held
in respect of the said debt are the following (5).
And I make this solemn declaration conscientiously be-
lieving the same to be true, and by virtue of an Act of the
General Assembly of New Zealand intituled “The Justices
of the Peace Act, 1882.”
Declared at , this day of , 18 , before
me—
A Justice of the Peace [or Solicitor of
the Supreme Court of New Zealand,
or Notary Public].

(1) If the proceedings are in a local Court the following must be
used: “In the District Court of (being a local Court of Bank-
ruptcy) holden at . (2) Christian names and surname of
bankrupt. (3) Address. (4) Occupation. (5) Name of creditor in full,
with occupation and address. (6) Name of creditor. (7) Here state
particulars of securities held, if any, and the estimated value of
each security.

—

No. 4.
PROXY.

In the matter of “The Bankruptcy Act, 1883,” and
of the bankruptcy of , of , in the
(1) of , a bankrupt.
, of , in the (1) of ,
in New Zealand, is hereby appointed proxy to act and vote on
my behalf at a (2) meeting of creditors to be held in
the matter of the said bankruptcy [(3) at , on the
day of , 18 ].
Dated at , this day of , 18 .
Creditor.

Witness to signature—
A Justice of the Peace [or Solicitor of
the Supreme Court, or Postmaster
at aforesaid].

NOTE.—The foregoing proxy does not authorize the holder to use
it in voting for the appointment of himself as Supervisor, but, if
such authority is intended to be conferred by the creditor, a special
form must be used.
(1) County or borough. (2) “Special meeting” or “at all meetings.”
(3) Omit this if proxy is to be a general one.

—

No. 5.
ACCEPTANCE OF OFFICE BY SUPERVISOR.

I, the undersigned, do hereby declare my acceptance of the
office of Supervisor in the bankruptcy of , of ,
upon the terms mentioned in the resolution appointing
me , passed by the creditors of the said ,
on the day of , 18 .
Dated this day of , 18 .
Supervisor.

Witness to signature (1)—
(1) Name, occupation, and address of witness.

—

No. 6.
VERIFICATION OF PETITION (WHEN ONE CREDITOR ONLY
PETITIONS).

I, A.B., the petitioner named and described in the within-
written petition, do hereby swear—

1. That the several statements in the said petition are
   within my own knowledge true in every particular.
   A.B.

Sworn at , this day
of , 18 , before me,—
C.D.,
A Solicitor of the Supreme Court
of New Zealand.

NOTE.—If the petitioner cannot depose to the truth of all the
material statements in the petition, he must set forth the state-
ments the truth of which he can depose to, and file a further affi-
davit by some person or persons who can depose to the truth of the
remaining statements.

—

No. 7.
VERIFICATION OF PETITION (WHEN MORE THAN ONE
CREDITOR PETITIONS).

WE, A.B., C.D., and E.F., the petitioners named in the
within-written petition, do hereby severally swear,
And, first, I, the said A.B., for myself say—

1. That (1) , the debtor named and described in
   the said petition, is justly and truly indebted to me in the
   sum of , as stated in the said petition, and that the
   said (1) committed the act of bankruptcy stated to
   have been committed by him in the said petition.
   And I, the said C.D., for myself say—
2. That the said (1) is justly and truly indebted to
   me in the sum of , as stated in the said petition.
   And I, the said E.F., for myself say—
3. That the said (1) is justly and truly indebted to
   me in the sum of , as stated in the said petition.
   A.B.
   C.D.
   E.F.

Severally sworn by the above-named deponents, A.B.,
C.D., E.F., at , this day of , 18 ,
before me—
G.H.,
A Solicitor of the Supreme Court of
New Zealand.

(1) Name of debtor.
[See note to Form No. 6.]

—

No. 8.

In the (1)
In the matter of “The Bankruptcy Act, 1883,” and
in the matter of (2) , of (3) ,
(4) , a bankrupt.
I, A.B., the above-mentioned bankrupt, do solemnly and sin-
cerely declare—

1. That the statement hereunto annexed, and marked “A,”
   contains, with the lists thereto attached, marked “B,” “C,”
   “D” and “E,” respectively, is a true statement showing the
   particulars of my assets and liabilities, the names, resi-
   dences, and occupations of my creditors, and the securities
   held by them respectively.
   And I make this solemn declaration conscientiously be-
   lieving the same to be true, and by virtue of the provisions
   of an Act of the General Assembly of New Zealand intituled
   “The Justices of the Peace Act, 1882.”

Declared at , this day of , 18 ,
before me—
C.D.,
A Justice of the Peace [or Solicitor of
the Supreme Court of New Zealand,
or Notary Public].

(1) Title of Court. (2) Name of bankrupt. (3) Residence. (4) Occu-
pation.

—

No. 9.
A.—STATEMENT OF BANKRUPT (AS REQUIRED BY SECTION 59 OF “THE BANKRUPTCY
ACT, 1883.”