2600

THE NEW ZEALAND GAZETTE.

[No. 68

I forward herewith the title-deeds of the property, together with plans and specifications of the dwellinghouse which I intend to erect. I agree to insure the dwellinghouse in the State Fire Insurance Office, and to pay, on demand, any costs and expenses arising out of this application whether the transaction be completed or not.

Signature of Applicant :
Occupation :
Address :

1. Have you previously had a loan from the Department; and, if so, when ?
2. What is amount of loan required (maximum £450, but must not exceed value of building) ?
3. Is loan required to pay for erecting or for acquiring a dwellinghouse ?
4. Is applicant married or about to be married ? State age :
5. State (a) whether the proposed security is freehold or leasehold :
   (b) whether the proposed security is urban or suburban :
6. If freehold, is the title registered under the Land Transfer Act or under the Deeds Registration Act ?
7. If leasehold, what is the class of lease (copy of the lease is required and must be sent with this application) ?
8. State numbers of sections or allotments and block, also road or street and local district :
9. Measurement of frontage to street or road :
10. Depth of land :
11. Area :
12. Are you the registered owner of the property ? If not, who is ?
13. When and from whom did [will] you acquire the land ?
    State the amount of the purchase-money (if any) :
14. Is the property already mortgaged ? If so, state amount and to whom :
15. Where are the title-deeds to be obtained ?
16. If about to build (and to utilize one of Department’s plans) state which plan is required :
    (a.) State how it is proposed to proceed with the building, whether by contract or otherwise :
    (b.) Give name of builder, and his contract price for all work required :
    (c.) State whether any iron stoves, wood or iron chimneys, or wood or iron fireplaces, stove-pipes, &c., are built or proposed ; and, if so, how secured :
    (d.) State value, and amount of insurance which should be obtainable :
17. State present value of the—
    Land unimproved .. .. .. £ : :
    Also, if building already erected, the value of the—
    Dwellinghouse .. .. .. £ : :
    Fencing .. .. .. £ : :
    Other improvements .. .. .. £ : :
    ————————
    Total .. .. .. £ : :
18. Notice of this application was posted on the day of , 191 , to the Commissioner of Crown Lands at
    [This is required in the case of a Crown leasehold only].

STATUTORY DECLARATION.

I [We],* , of , do [jointly and severally] solemnly and sincerely declare—

1. That, subject to the provisions of the New Zealand State-guaranteed Advances Act, 1909, and the New Zealand State-guaranteed Advances Amendment Act, 1910 (relating to Advances to Workers) I [we] desire a loan for the sole purpose of erecting or acquiring a home for myself [ourselves] and my [our] family.
2. That I, the said [Fill in husband’s full name], am employed as by .
3. That I am [we are] not in receipt of an income of more than two hundred pounds per annum from all sources.
4. That I am [we are] not the owner[s] of any land other than the land which I [we] offer as security for the loan for which application is made.
5. That I am [we are] over twenty-one years of age.
6. That I [we] will forthwith on completion of the dwellinghouse or on acquiring such home as aforesaid reside permanently on the property.
   And I [we jointly and severally] make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Justices of the Peace Act, 1908.
   Signature :
   [Severally] declared at , this day of , 191 , before me— , a Justice of the Peace [or Solicitor].

• When the applicant is a married woman the declaration must be made by her and her husband.

J. F. ANDREWS,
Clerk of the Executive Council.