Jan. 19.] THE NEW ZEALAND GAZETTE. 133

as are required from time to time, on requisition in the following form :—

Requisition to pay Moneys out of Fund.
National Provident Fund,
, 191* .

The Public Trustee.
REQUISITION is hereby made to pay to the sum of £ , for the purposes of the National Provident Fund Act, 1910.
, Superintendent of the Fund.
, Minister of Finance for the Board.

Form A.
National Provident Fund Act, 1910.
FORM OF APPLICATION TO BECOME A CONTRIBUTOR TO THE NATIONAL PROVIDENT FUND.

To the Superintendent of the Fund.
I HEREBY apply to become a contributor to the Fund, and declare the following particulars to be correct to the best of my knowledge and belief :—
Name in full :
Place of residence [Give full address] :
Sex :
Date of Birth : Place of Birth :
Age next birthday :
Occupation :
Married or single :
Amount of weekly contribution :
Amount of weekly pension required :
I also declare that during the three years preceding the date of this application my income has not exceeded the average sum of £200 a year.
[Signature of Contributor.]
[Date.]

Form B.
National Provident Fund Act, 1910.
FORM OF ELECTION TO INCREASE [or REDUCE] RATE OF CONTRIBUTIONS.

To the Superintendent of the Fund.
I, [Name in full], being a contributor to the National Provident Fund, hereby elect to increase [or reduce] the rate of my weekly contribution to that Fund to , so as to increase [or reduce] my pension to a week.
[Signature.]
[Date.]

Form C.
National Provident Fund Act, 1910.
FORM OF ELECTION TO CEASE TO BE A CONTRIBUTOR.

To the Superintendent of the Fund.
I, [Name in full], being a contributor to the National Provident Fund, hereby formally give notice that I elect to cease to be a contributor to the said Fund, and I hereby apply for a refund at the end of twelve months from the date hereof of my contributions, less any sums received by me from the Fund by way of benefits, and I agree to renounce as from the date hereof all rights to future benefits from the said Fund.
[Signature.]
[Date.]

Form D.
National Provident Fund Act, 1910.
NOTICE OF CESSATION OF PAYMENTS BY EMPLOYER.

NOTICE is hereby given that the contributions of [Name in full] will cease to be paid with the other employees of [Name of firm] as from .
[Signature of employer.]

Form E.
National Provident Fund Act, 1910.
APPLICATION BY CONTRIBUTOR FOR MATERNITY BENEFIT.
, 191 .

The Superintendent, National Provident Fund,
Wellington.

Name of claimant [in full] :
Residence :
Date of birth of child :
Sex of child :

Name of medical attendant (if any) (or of midwife if no medical attendant) :
Name of nurse :

I HEREBY claim for medical attendance in respect of the birth of the above child the sum of £ : : , made up as follows :—
Doctor’s (or midwife’s) account ... £ : :
Nurse’s account ... ...
Total ... ... ... £

[Signature of claimant.]

N.B.—The total claim must not exceed £6.

“A.”

Statutory Declaration.

I, [Name in full], of [Residence and occupation], do solemnly and sincerely declare that the joint income of myself and my wife [or husband] during the period of twelve months preceding the date of the birth of my child referred to in the foregoing application did not exceed two hundred pounds.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1908.

[Signature of declarant.]

Declared at , this , day of 191 , before me— , Justice of the Peace [or Solicitor of the Supreme Court].

Form F.
National Provident Fund Act, 1910.
APPLICATION FOR INCAPACITY ALLOWANCE.

The Superintendent, National Provident Fund,
Wellington.

I, a continuous contributor to the National Provident Fund, hereby claim a weekly allowance of £ : : , representing 7s. 6d. per week for of my children under fourteen years of age, on the ground that I have been wholly incapacitated from carrying on my trade [business, employment, calling, or occupation] for more than three months, and am still wholly incapacitated.

I declare the following particulars to be true and correct to the best of my knowledge and belief :—
(1.) Cause of incapacity :
(2.) Duration of incapacity :
(3.) Where last employed :
(4.) If incapacity arose out of an accident, give date of accident, and explain fully how accident happened :
(5.) If incapacity arose out of an illness, state nature of illness, and give date of original commencement of such illness :
(6.) Is the incapacity due to your serious misconduct?
(7.) What pecuniary loss have you suffered by the incapacity, and how is it made up? State weekly income received before incapacity :
(8.) State total income per week at present received or due, as follows :—
From employer ... ... £ : :
,, Workers’ Compensation ...
,, friendly societies ...
,, other sources ...
Total ... ... £

[Signature of contributor.]
[Date.]

J. F. ANDREWS,
Clerk of the Executive Council

Revoking Order in Council licensing Edward Johnson to use and occupy a Part of the Foreshore of Horse-shoe Bay, Stewart Island, as a Site for a Fish-shed.

ISLINGTON, Governor.
ORDER IN COUNCIL.

At the Government House, at Wellington, this ninth day of January, 1911.

Present :

HIS EXCELLENCY THE GOVERNOR IN COUNCIL.

WHEREAS by an Order in Council dated the fifth day of March, one thousand nine hundred and ten, and published in the New Zealand Gazette No. 21, of the tenth day of the same month, a license was granted