3304
THE NEW ZEALAND GAZETTE.
[No. 120

(2.) That my wife was resident in New Zealand at the time of the birth of the child.
(3.) That I am not claiming the maternity allowance in respect of this birth from another friendly society or from the National Provident Fund as a contributor under the National Provident Fund 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.

Signature of declarant :

Declared at this day of , 191 ,
before me—

…………
Justice of the Peace
[or Solicitor of the Supreme Court].

If the wife wishes to authorize the payment of the allowance to her husband, she must sign the following form of authority :—

• I hereby authorize the payment of this allowance to my husband, and authorize my husband to sign a receipt on my behalf.

Wife’s signature :

CERTIFICATE.

I hereby certify that gave birth to a child on , and was attended by me during her confinement.

Signed [Add any qualifications] :
Date :

(For Use by Branch.)

Member qualified ?
…………
[Signature of Secretary.]

RECEIPT FROM WIFE, OR HUSBAND ON HER BEHALF (IF AUTHORIZED, SEE * ABOVE).

Received the sum of in cash.

Signature :
Date :

NOTE.—If the husband has been authorized to sign, he should sign “for” his wife, thus : “Thomas Smith (for Mary Smith).”

(For Central Body’s Use.)

Date : . Noted : . Initials : .

SECOND RECEIPT FROM WIFE, OR HUSBAND ON HER BEHALF (IF AUTHORIZED, SEE * ABOVE).

[To be retained by Branch Secretary.]

Received the sum of in cash.

Signature :
Date :

[Form A.S.—2.

National Provident Fund.

APPLICATION FROM MEMBER OF FRIENDLY SOCIETY TO CONTRIBUTE.

To the Superintendent of the Fund.

I HEREBY apply through the Society 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] :
Business address :
Date of birth : Sex :
Place of birth :
Age last birthday :
Occupation :
Married or single :
If married woman or widow give maiden name :
Amount of weekly contribution :
Amount of weekly pension required :

[Signature of member.]

Date : , 191 .

Declaration to be signed by contributors who joined the society after 31st December, 1916, and by all contributors after 31st December, 1917.

I also declare that during the three years preceding the date of this application my income has not exceeded the average sum of £250 a year.

[Signature.]

Contributions amounting to £ : : received and interim receipt given for same.

[Signature of Secretary.]

[F.S.
National Provident Fund.
PAY-IN SLIP TO BE FORWARDED TO SUPERINTENDENT.

I HEREBY pay the sum of pounds shillings and pence, being the contributions to the above-named Fund on account of [State name of contributor].

[Signature of Payer-in.]
[Signature of Secretary.]

Amount. £ s. d.
Date :
Name of branch and district :

[A.S.—3.
National Provident Fund.
CONTRIBUTOR’S RECEIPT.

Name :
RECEIVED the sum of pounds shillings and pence.
£ : :
[Signature of Secretary.]
Date :
Name of Branch :
[To be retained by Branch Secretary.]

National Provident Fund.
APPROVED FRIENDLY SOCIETY.

Name of branch (and society) :

RETURN of pension contributions received by the above-named branch from members during the period to .

Name :
Amount :
…………
Secretary of Branch.

(For Central Body’s Use only.)

Noted in society account.

[Signature of secretary of central body.]
[Date of entry.]

As witness the hand of His Excellency the Governor, this tenth day of October, one thousand nine hundred and sixteen

ARTHUR M. MYERS.

Changing the Purpose of a Reserve in Mangaone Survey District, Wellington Land District.

LIVERPOOL, Governor.

WHEREAS the land described in the Schedule hereto has been duly set apart for gravel purposes, being a reserve within Class I of the Second Schedule of the Public Reserves and Domains Act, 1908, and such land is not vested in trust in any society, body corporate, or trustees :