April 3.] THE NEW ZEALAND GAZETTE. 581

I, , being the duly-appointed public officer of the above-named company, and in that capacity duly authorised
to make the foregoing return, do solemnly and sincerely declare that I am well acquainted with the affairs of the said
company, and that the said return and the statements therein referred to or accompanying such return contain true and
accurate details of the several matters and things set forth, and in particular contain a true and accurate account of all
land in New Zealand owned by such company as at noon on the 31st day of March, 189 , and of all mortgages of land in
New Zealand held by such company on the same date, and that the mortgages for which deduction is claimed are mort-
gages which the company is legally entitled to deduct. And I make this declaration under the provisions of “The Land
and Income Assessment Act, 1891,” and its amendments, and as such public officer as aforesaid.

Dated this day of , 189 .

Usual signature: .

[All letters, &c., should be addressed “The Commissioner of Taxes, Wellington,” and not to any name. Letters so addressed go free
by post.]

Particulars of Money lent by the Company secured on Registered Mortgage, and any Amount owing in respect of Land
sold on Time or Deferred Payment.

| Person to whom the Money is lent. | | | Amount of Mortgage. | Amount owing on 31st
March, 189 ,
not including Interest.
(The actual value of
the mortgage to be
inserted.) |
| --- | --- | --- | --- | --- |
| Name. | Occupation. | Address. | £ | £ |

Particulars of Money owing by the Company secured on Registered Mortgage, and any Amount owing on Land
purchased on Time or Deferred Payment.

| Person to whom the Money is owing. | | | Amount of Mortgage. | Amount owing on
31st March, 189 , not
including Interest. |
| --- | --- | --- | --- | --- |
| Name. | Occupation. | Address. | £ | £ |

[NOTE.—In the case of mortgagees who are not resident in New Zealand, the names and addresses of their agents should also be stated.]

Particulars of Land.

| Assessment
No. | Local District or Borough. | Freehold or
Leasehold. | No. of Section or
Allotment. | Street or Particular
Locality. | Area. | Unimproved
Value. |
| --- | --- | --- | --- | --- | --- | --- |
| | | | | | A. R. P. | £ |

[NOTE.—The unimproved value of each property should be shown separately. In the case of leased properties the owner's or lease-
holder's interest in the land should be stated.]

SCHEDULE C.

"THE LAND AND INCOME ASSESSMENT ACT, 1891."

In pursuance of the above Act, and of the regulations made thereunder, every person in receipt of income within the
meaning of the said Act is required to fill up the following return as far as is applicable to his particular case, and deliver
the same at, or forward it by post to, the office of the Commissioner of Taxes, Wellington, on or before the day of ,
189 , Commissioner of Taxes.

[NOTE.—Any person failing or neglecting to furnish a return at the prescribed time, or any person making a false return, is liable
to a penalty of not less than £5 nor more than £100, and to pay treble extra duty.]

Return of the Income of

[Name in full], [postal address], [occupation], made in pursuance of "The Land and Income Assessment Act, 1891," and the regulations thereunder.

INCOME DERIVED DURING THE YEAR ENDING 31st MARCH, 189 .

Gross Income derived from Business.

1: From interest of money deposited or lodged with any bank, society, company, firm, or person ..
2: From interest on bonds, debentures, or like instruments .. .. .. .. ..
3: From annuities or other annual payments .. .. .. .. ..
4: From the trade, business, manufacture, or concern of carried on by me at (as per
details shown on page 3) .. .. .. .. .. ..
5: From pastoral lands of the Crown .. .. .. .. .. ..
6: From mining on Crown lands .. .. .. .. .. ..
7: From dividends paid or profits credited by any building society .. .. .. ..
8: From any source not coming within any of the foregoing heads (State source) .. .. ..

Total .. .. .. .. .. .. £

[N.B.—Dividends and debenture interest received from companies trading within the colony should not be
included as income.
Income derived from any source whatsoever beyond the colony and received in the colony should be included
in this return.]

Deductions (as per details shown on page 3).

Losses, outgoings, and expenses incurred in the production of the gross income stated above .. £

Net income derived from business .. .. .. .. £

[N.B.—Interest on mortgages, except mortgages on premises used for business or employment, and land- and income-tax paid cannot
be deducted.]