SEPT. 9.] THE NEW ZEALAND GAZETTE. 3173

SCHEDULE.
Part I.
PARTICULARS OF WORKER’S DWELLING.
Site:—

1. Particular locality desired (if any):
2. Approximate size of section desired [Where workers’
   dwellings land is available, specify number of section
   or portion desired]*:
   Dwelling:—
3. Number of rooms required:
4. Number of design selected*:
5. Any other particulars concerning land or dwelling that
   applicant desires to submit:

• Designs of dwellings may be inspected, and particulars
  of land available (if any) may be obtained, at the nearest
  office of the Department of Labour; the Board will be
  prepared to consider any reasonable alterations of designs to
  suit the requirements of applicants.

Part II.
PARTICULARS AS TO APPLICANT.

1. Age:
2. Occupation:
3. State whether married or single:
4. Name and address of employer:
5. Rate of earnings at time of application:
6. 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 a weekly [or monthly]
tenancy of (a) [in the case of a dwelling 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 one pound (£1), being the
amount of fee required by section 7 of the Amendment Act,
1914.
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 desired [Where workers’
   dwellings land is available, specify number of section
   or portion desired]*:
   Dwelling:—
3. Number of rooms required:
4. Number of design selected*:
5. Any other particulars concerning land or dwelling that
   applicant desires to submit:

• Designs of dwellings may be inspected, and particulars
  of land available (if any) may be obtained, at the nearest
  office of the Department of Labour; the Board will be pre-
  pared to consider any reasonable alterations of designs to
  suit the requirements of applicants.

Part II.
PARTICULARS AS TO APPLICANT.

1. Age:
2. Occupation:
3. State whether married or single:
4. Name and address of employer:
5. Rate of earnings at time of application:
6. 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, that my earnings do not
exceed £175 per annum, and that I am not, either by myself
or conjointly with any person, the owner in fee-simple or the
tenant or occupier under a lease of any land in New Zealand.
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 fe-
male, who is employed in work of any kind in manual labour,
or 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
(hereinafter called “the Superintendent”), 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 (hereinafter called “the
purchaser”), of the other part, whereby it is agreed as
follows:—
(1.) Subject to the provisions of the said Act and of the
regulations thereunder the Superintendent agrees to sell
and the purchaser agrees to purchase [Strike out (a) or (b),
as the case may be] (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
dwelling already erected] the worker’s dwelling being [Specify
number, street, and other particulars sufficient to identify the
dwelling].
(2.) That the purchaser shall pay to the Superintendent
aforesaid, at such place as the Superintendent may from time
to time direct, the sum of 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.
(3.) That the purchaser shall, in addition, pay to the
Superintendent the amount of premium required, as deter-
mined by the Superintendent, to insure the dwelling against
loss by fire or other cause, and the amount of rates to be
levied by the local authority from time to time.
(4.) Such payments shall be made by instalments
of , consisting partly of principal, partly of interest,
and partly of insurance premium and rates, and shall extend
over a period of years.
(5.) That the purchaser shall enter into possession (a) not
later than fourteen days after notice of the date of the com-
pletion of the dwelling has been given to the purchaser by
or on behalf of the Superintendent, (b) as from the
day of , 19 ; and the instalments aforesaid shall
be calculated as from such date of entry into possession.
(6.) That the purchaser shall have all exterior woodwork
of the dwelling painted with two coats of paint at least every
five years, and all exterior metalwork shall be painted with
one coat of paint at least once in five years.
(7.) 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.
(8.) The purchaser hereby acknowledges to have received
on the execution hereof a copy of the said Act and the regula-
tions thereunder.
In witness whereof the parties have hereunto set their
hands the day and year first above written.

Signed by the Superintendent of the 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. Number of departmental design in accordance with
   which the building is to be erected:
4. Capital value:
5. Any other particulars concerning land or building: