April 3.] THE NEW ZEALAND GAZETTE. 587

List of Directors, Auditors, and Others to whom any Payment has been made.

[All amounts paid should be included in this list.]

[If there should not be sufficient space in any of the above forms, a sheet giving the required information may be attached.]

Particulars of Investments.

SCHEDULE G.

"THE LAND AND INCOME ASSESSMENT ACT, 1891."

In pursuance of the above Act, and of the regulations made thereunder, every company 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 its 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_____.

[Note.—Any company failing or neglecting to furnish a return at the prescribed time, or any company making a false return, is liable to a penalty of not less than £5 or more than £100, and to pay treble extra duty.]

Return of Dividends,

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

Dividends paid during the year ending 31st March, 189_: £____

I, __, being the duly-appointed public officer of the above-named company, and in that capacity duly authorised to make the above return, do solemnly and sincerely declare that I am well acquainted with the affairs of the said company, and that the said return contains a true and accurate statement of the dividends paid by the company for the year ending the 31st March, 189, and that a copy of a balance-sheet hereto attached is a true copy of the balance-sheet of the said company issued to shareholders, or prepared for issue, last prior to the date of this return.

Dated this day of , 189____.

Usual signature: _____

Return as Agent for Holders of Debentures.

Return of the income received or receivable for the year ending 31st March, 189_, by the holders of debentures issued by the ___ Company in respect of money borrowed on debentures by the company: £__

I, __, being the duly-appointed public officer of the above-named company, and in that capacity duly authorised to make the above return, do solemnly and sincerely declare that I am well acquainted with the affairs of the said company, and that the said return contains a true and accurate statement of the income for the year ending the 31st March, 189, of the debenture-holders in respect of money lent to the said company on debentures.

Dated this day of , 189____.

Usual signature: _____

STATEMENT to be made by Government Departments, Local Authorities, Persons, Firms, Companies, and Societies employing Officers, Managers, Travellers, Clerks, Foremen, Workmen, Servants, and others in New Zealand, whether paid by Salary, Weekly Wage, or Otherwise.

List of Persons in the Service or Employ of the Company.

[In the case of any person the total payment to whom does not exceed £160 a year an entry need not be made.]

List of Directors, Auditors, and Others to whom any Payment has been made.

[All amounts should be entered in this list.]

[If there should not be sufficient space in either of the above forms, a sheet giving the required information may be attached.]

B