890
THE NEW ZEALAND GAZETTE.
[No. 17

Part II.
Particulars as to Applicant.

1. Whether over twenty-one years of age or not :
2. Whether married or single :
3. Where employed :
4. Rate of earnings at time of application :
5. Proposed occupants of worker’s dwelling, stating the ages and sexes of children :

Form W.D. 1c.
APPLICATION FOR WEEKLY [or MONTHLY] TENANCY OF A WORKER’S DWELLING.

(Under Section 8 of the Workers’ Dwellings Act, 1910.)

To the Superintendent of Workers’ Dwellings, Wellington.

I, [Name in full], of [Address], [Occupation], hereby apply to the Workers’ Dwellings Board for the district for a weekly [or monthly] tenancy of (a) [in the case of a building already erected] the worker’s dwelling, being [Specify number, street, and other particulars sufficient to identify the dwelling]; or (b) a worker’s dwelling to be erected in accordance with the particulars set out in the First Part of the Schedule hereto.

I enclose herewith the sum of __ pounds (£__), being the deposit of four weeks’ rent in advance, payable in accordance with regulations under the above-mentioned Act.

I also enclose statutory declaration (Form W.D. 1d) made by me in accordance with section 8 of the said Act, and I further declare that the particulars set out in the Second Part of the Schedule hereto are correct.

Dated at __, this __ day of __, 19____.

[Signature of Applicant.]

SCHEDULE
Part I.
Particulars of Worker’s Dwelling.
Site :—

1. Particular locality desired (if any) :
2. Approximate size of section :

Dwelling :—
3. Number of rooms required :
4. No. of design selected* :
5. Any other particulars concerning land or dwelling that applicant desires to submit :

• Designs may be inspected at the nearest office of the Department of Labour, and the Board will be prepared to consider any reasonable alterations of same to suit the convenience of applicant.

Part II.
Particulars as to Applicant.

1. Whether over twenty-one years of age or not :
2. Whether married or single :
3. Where employed :
4. Rate of earnings at time of application :
5. Proposed occupants of worker’s dwelling, stating the ages and sexes of children :

Form W.D. 1d.
STATUTORY DECLARATION.

(Under Section 8 of the Workers’ Dwellings Act, 1910.)

I, [Name in full], of [Address], [Occupation], do solemnly and sincerely declare that I am a “worker” within the meaning of the Workers’ Dwellings Act, 1910. And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1908.

Declared at __, this __ day of __, 19, before me—__, Justice of the Peace [or Solicitor].

Definition of “Worker.”

Section 2. “Worker” means every person, male or female, who is employed in work of any kind or in manual labour, whose earnings at the time of his application do not exceed one hundred and seventy-five pounds per annum, and who is landless—meaning thereby that he is not, either by himself or jointly with any other person, the owner in fee-simple or the tenant or occupier under a lease of any land in New Zealand.

Form W.D. 2a.
AGREEMENT TO PURCHASE A WORKER’S DWELLING.

(Under Section 9 of the Workers’ Dwellings Act, 1910.)

MEMORANDUM of agreement made this __ day of __, 19____, between the Superintendent of Workers’ Dwellings, on behalf of His Majesty the King, of the one part, and [Name in full, address, and occupation], a worker within the meaning of the Workers’ Dwellings Act, 1910, of the other part.

Subject to the provisions of the said Act, and of the regulations thereunder, the Superintendent agrees to sell, and the said __ agrees to purchase, (a) a worker’s dwelling to be erected on the land described in the Schedule hereto in accordance with the particulars set out therein; or (b) [in the case of a building already erected] the worker’s dwelling, being [Specify number, street, and other particulars sufficient to identify the dwelling].

It is also agreed that the said __ shall pay to the Superintendent aforesaid, at such place as the Superintendent may from time to time direct, the sum of __ pounds as purchase-money (being the capital value of the said dwelling, less the deposit of ten pounds paid in advance), together with interest thereon at the rate of five pounds per centum per annum. Such payments shall be made by weekly [fortnightly or monthly] instalments of __ pounds (consisting partly of principal and partly of interest), and shall extend over a period of twenty-five and a half years. The first of such instalments shall be paid on (a) the __ day of __, 19; or (b) as from a date to be hereinafter fixed by the Superintendent (being not later than fourteen days after notice of the completion of the building has been given to the said __).

And it is hereby further expressly stipulated and agreed that this agreement is entered into subject to the provisions and conditions relating thereto contained in the Workers’ Dwellings Act, 1910, and the regulations at present in force thereunder, which said provisions and conditions shall be deemed to be contained herein.

In witness whereof the parties hereto have hereunto set their hands, the day and year first above written.

Signed by the Superintendent of Workers’ Dwellings, in the presence of—

Signed by the said __, in the presence of—

SCHEDULE.
Site :—

1. Description and area of section :
   Dwelling :—
2. Number of rooms :
3. No. of departmental design in accordance with which building to be erected :
4. Capital value :
5. Any other particulars concerning land or building :

Form W.D. 2b.
AGREEMENT FOR RENEWABLE LEASE OF WORKER’S DWELLING.

(Under Section 9 of the Workers’ Dwellings Act, 1910.)

MEMORANDUM of agreement made this __ day of __, 19____, between the Superintendent of Workers’ Dwellings, on behalf of His Majesty the King, of the one part, and [Name in full, address, and occupation], a worker within the meaning of the Workers’ Dwellings Act, 1910, of the other part.

Subject to the provisions of the said Act, and of the regulations thereunder, the Superintendent agrees to grant, and the said __ agrees to accept, a renewable lease for a term of twenty-one years of (a) [in the case of a building already erected] the worker’s dwelling being [Specify number, street, and other particulars sufficient to identify the dwelling], as from the __ day of __, 19; or (b) a worker’s dwelling to be erected on the land described in the Schedule hereto in accordance with the particulars set out therein, as from a date to be hereafter fixed by the Superintendent (being not later than fourteen days after notice of the completion of the building has been given to the said __).

It is also agreed that the said __ shall pay to the Superintendent aforesaid by weekly [or monthly] payments, at such place as the Superintendent from time to time directs, the sum of __ per annum as rent in respect to the said dwelling.

And it is hereby further expressly stipulated and agreed that this agreement is entered into subject to the provisions and conditions relating thereto contained in the Workers’ Dwellings Act, 1910, and the regulations at pre-