Now, therefore, it is ordered that unless the defendant shall pay into this Court at forth- with [or on or before the day of , 19 , or by instalments of £ on the day of each , commencing on the day of , 19 ] the sum stated below, as that upon the payment of which he is to be discharged, or shall file such affidavit as is mentioned in Rule 36 of the Rules for Magistrates' Courts under the Imprisonment for Debt Limitation Act, 1908, he shall be committed to the public prison at , known as the , for .

Given under my hand, and the seal of the Court, this day of , 19 .

, Stipendiary Magistrate.

Amount of judgment [or order] remaining due
Costs of judgment summons
Total sum upon payment of which the order will be discharged
Subject as above, this order remains in force for one year from the date hereof.

I, , Bailiff of the Magistrate's Court holden at , do hereby make oath and say:

1. That I duly served the within , the defendant, with an order on a judgment summons a true copy of which said order is endorsed hereon, by delivering the same to him personally at on the day of , 19 .

Sworn at , this day of , 19 , before me, , Clerk of Court [or Justice of the Peace for New Zealand, or Solicitor].

[Debt Form 21.
ORDER ON AN ORDER OR JUDGMENT OF A COURT OTHER THAN THE COURT IN WHICH THE JUDGMENT WAS OBTAINED.

The Imprisonment for Debt Limitation Act, 1908, and the Magistrates’ Courts Act, 1908.
No. of plaint: /19 . No. of judgment summons: /19 . No. of order: /19 .
In the Magistrate’s Court holden at

Between , of , plaintiff, and , of , defendant.
WHEREAS the plaintiff obtained a judgment against the defendant in the Court [or as the case may be] holden at , on the day of , 19 , for the sum of £ , and there is now due and payable upon the said judgment the sum of £ :

[Or, Whereas by a decree (or order) made by the Court [or as the case may be] holden at , on the day of , 19 , the defendant was ordered to pay to the plaintiff the sum of £ , and there is now due and payable upon the said decree (or order) the sum of £ :]

And whereas the said judgment or order was removed into this Court by certificate of judgment [or under section 139 of the Magistrates’ Courts Act, 1908] and a summons was, at the instance of the plaintiff, duly issued out of this Court by which the defendant was required to appear personally at this Court on the day of , 19 , to be examined on oath as to whether [Here specify such of the matters as were stated in the summons]—

(1.) After providing for the reasonable maintenance of himself and his family he had not since the date of the judgment [or decree, or order] had sufficient money to pay the debt; or

(2.) He had not since the date of the order to pay the debt by instalments had sufficient money to pay the instalment so due ; or

(3.) [If fraud is alleged state specifically];
and also to show cause why he should not be committed to prison for such default, which summons was proved to this Court to have been duly served on the defendant:

And whereas at the hearing of the said summons it has now been proved to the satisfaction of the Court that the defendant [Here specify such of the matters stated in the summons as have been proved]—

(1.) After providing for the reasonable maintenance of himself and his family, has since the date of the judgment [or decree, or order] had sufficient money to pay the debt; or

(2.) Has since the date of the order to pay the debt by instalments had sufficient money to pay the instalment so due ; or

(3.) [If fraud is proved state specifically]; or

(4.) The defendant did not appear, as required by such summons, nor allege a sufficient cause for not attending;

and the defendant has shown no cause why he should not be committed to prison: