APRIL 4.] THE NEW ZEALAND GAZETTE. 1219

Regulations under the National Provident Fund Act, 1910.

ISLINGTON, Governor.

ORDER IN COUNCIL.

At the Government Buildings, at Wellington, this twenty-eighth day of March, 1912.

Present:

THE RIGHT HONOURABLE SIR J. G. WARD, BART., PRESIDING IN COUNCIL.

IN pursuance and exercise of the power and authority conferred upon him by the National Provident Fund Act, 1910 (hereinafter referred to as “the said Act”), His Excellency the Governor of the Dominion of New Zealand, acting by and with the advice and consent of the Executive Council of the said Dominion, doth hereby amend and supplement in the manner hereinafter set forth the regulations made under the said Act on the ninth day of January, one thousand nine hundred and eleven, and published in the Gazette of the nineteenth day of the same month.

REGULATIONS.

1. THE forms E and F of the regulations hereinbefore referred to are hereby revoked, and the forms E and F in the First Schedule hereto are respectively substituted therefor.

2. The statements required by section 23 of the said Act to be prepared by the Board shall be in the forms numbered (1), (2), and (3) respectively in the Second Schedule hereto.

FIRST SCHEDULE.

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-mentioned child the sum of £

made up as follows :—

Doctor’s (or midwife’s) account . . . . . . . . . . . . £ s. d.
Nurse’s account . . . . . . . . . . . . . . . . . . : :
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£ : :
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N.B.—The total claim must not exceed £6.

“A.”

[Signature of Claimant.]

STATUTORY DECLARATION.

I, [Name in full], of [Residence and occupation], do solemnly and sincerely declare as follows :—

1. That the joint income of myself and my wife [or husband] during the period of twelve months immediately preceding the date of the birth of my child referred to in the foregoing application did not exceed £200.

2. That I have not at any time since I became a contributor been absent from New Zealand for a longer period than two years at any one time, or for a longer period in the aggregate than five years.

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 , 191 , before me—

[Signature of declarant.]

, 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 [Name in full, address, and occupation], 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 . . . . . . . . . . . . £ s. d.
From workers’ compensation . . . . . . . . : :
From friendly societies . . . . . . . . . . : :
From other sources . . . . . . . . . . . . : :
——————————————————
£ : :
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And I also declare that I have not at any time since I became a contributor been absent from New Zealand for a longer period than two years at any one time, or for a longer period in the aggregate than five years.

[Date.]

[Signature of contributor.]