Regulations under the National Provident Fund Act, 1910.

LIVERPOOL, Governor.
ORDER IN COUNCIL.

At the Government Buildings at Wellington, this twenty-second day of February, 1916.

Present:
THE RIGHT HONOURABLE W. F. MASSEY, P.C., 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, and also the regulations made on the twenty-eighth day of March, one thousand nine hundred and twelve, and published in the Gazette of the fourth day of April, one thousand nine hundred and twelve.

REGULATION.

INCAPACITY BENEFIT.

1. THE form F of the regulations hereinbefore referred to is hereby revoked, and form F in the First Schedule hereto is substituted therefor.
   The Board may require a medical certificate to be furnished at such time or times as may be decided in each case.

CHILDREN’S ALLOWANCE.

2. The application for this benefit shall be on form G hereof, and shall be supported by a declaration in form H.

WARRANT APPOINTING AN AGENT.

3. Applications to appoint any person to act as an agent for the receipt of allowances due on behalf of any incapacitated beneficiary must be made in the form I.
   The person in whose favour the warrant is to be issued must be a reputable person, and must record his assent to act on the application form.

Form F.

National Provident Fund Act, 1910.

APPLICATION FOR INCAPACITY ALLOWANCE.

The Superintendent, National Provident Fund, Wellington.
I [Name in full], of [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 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:
   £ s. d.
   From employer ..
   From workers’ compensation ..
   From friendly societies ..
   From other sources ..
   £

9. State name and address of medical attendant:
   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.]
   [Address.]

N.B.—Absence from New Zealand for the purpose of receiving education, if such absence does not exceed five years, shall not be deemed to be absence for the purpose of this declaration.

Form G.

National Provident Fund Act, 1910.

APPLICATION FOR CHILDREN’S ALLOWANCE.

The Superintendent, National Provident Fund.
I , the widow of , who at his death was a continuous contributor to the National Provident Fund, hereby claim a weekly allowance of £ , representing 7s. 6d. per week for of his children under fourteen years of age and 7s. 6d. per week as his widow.

I attach herewith the following documents:
(1.) Certificate of death of contributor.
(2.) Marriage certificate.
(3.) Birth certificates of children.

I declare that the contributor has not, since becoming 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.

[Signature of widow.]

[Address.]

[Date.]

N.B.—Absence from New Zealand for the purpose of receiving education, if such absence does not exceed five years, shall not be deemed to be absence for the purpose of this declaration.

Form H.

National Provident Fund Act, 1910.

FORM OF DECLARATION.

DECLARATION AS TO IDENTITY OF CONTRIBUTOR TO THE NATIONAL PROVIDENT FUND MADE BY SOME RESPONSIBLE PERSON OTHER THAN CLAIMANT.

I [Name in full], of [Address and occupation], in the Dominion of New Zealand, hereby solemnly and sincerely declare:
That during his lifetime I knew and was well acquainted with [Full name of deceased contributor], of [Residence], who died at [Place of death], in the said Dominion, on the [Date of death] day of , 191 , and I had reason to believe that the said deceased was a contributor to the National Provident Fund, because [State generally any circumstances to show how the declarant became acquainted with the facts stated].
That I also know [The claimant], the [Relationship to deceased] of the said deceased, and who is now the claimant for allowances from the said fund.
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.]

Taken and declared at this day of , 191 , before me:

A Justice of the Peace for the Dominion of New Zealand [or Solicitor, or Notary Public, or Postmaster].

Form I.

National Provident Fund Act, 1910.

APPLICATION FOR WARRANT TO RECEIVE ALLOWANCE.

I , hereby request that a warrant be issued authorizing to receive allowances due to me from the National Provident Fund, as I am unable to attend at a paying-office owing to

[Signature of contributor.]

I assent.

[Signature of Agent.]

[Date.]

Form J.

National Provident Fund Act, 1910.

WARRANT TO RECEIVE ALLOWANCES.

THIS warrant authorizes , of , to receive the allowances due to from the National Provident Fund.

Superintendent of Fund.

Wellington [Date].

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