JAN. 8.] THE NEW ZEALAND GAZETTE. 41

If no local Fund’s office, state money-order office where payment to be made:
Date of birth of child: [Day] [Month] [Year].
Sex of child:
Christian name of child:
Name of medical attendant (if any): [If no medical attendant name midwife].
Name of nurse:
Date and amount of last two payments of contributions to the Fund: Date: . Amount: £ : : Date: . Amount: £ : :

I hereby claim for medical attendance in respect of the birth of the above child the sum of £ : : , made up as follows:—
Doctor’s (or midwife’s) account .. .. £ : :
Nurse’s account .. .. £ : :
Total .. .. .. £ : :
[Signature of claimant.]

If “still-birth” or “miscarriage” state particulars, including duration of pregnancy.
[Signature of medical attendant.]

N.B.—The total claim must not exceed £6.

“A.”

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 £300.
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.
3. That I have not claimed a maternity allowance from an approved friendly society in respect of this birth.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1908.
(Free of stamp duty.) [Signature of declarant.]

Declared at , this day of , 19 , before me— , Justice of the Peace [or Solicitor of the Supreme Court].

[A.S.—1.

National Provident Fund Act.

MATERNITY ALLOWANCE FOR MEMBERS OF FRIENDLY SOCIETIES.

Name of Society (Branch):
To the Secretary.

I HEREBY request that the maternity allowance payable to my wife in respect of the birth of a child, as certified below, should be paid.
Christian name of child:
Date of birth:
Place of birth: [Signature of member.]
[Present address.]

Date: Member’s number in his society: .

STATUTORY DECLARATION.

I [Name in full], of , 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 day of , 19 , being the date of the birth of my child, did not exceed £300.
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 , 19 , before me— Justice of the Peace [or Solicitor of the Supreme Court].

F

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 [Name in full] gave birth to a child on , and was attended by me during her confinement. If “still-birth” or “miscarriage” state particulars, including duration of pregnancy. Such claims must be referred to the Superintendent before payment.

Signed :†
Date:

† Add any qualifications.

(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.
[Date.] [Signature.]

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.]

[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: , 19 .

I also declare that during the three years preceding the date of this application my income has not exceeded the average sum of £300 a year. [Signature.]

Contributions amounting to £ : : received and interim receipt given for same. [Signature of Secretary.]

[Form K.

I [or We], the , do hereby transfer all rights in respect of Contract No. made on , under section 20 of the National Provident Fund Amendment Act, 1914, or under section 8 of the National Provident Fund Amendment Act, 1919, to and in favour of the person on behalf of whom the aforesaid contract was made.

[Signature of contributor on behalf of .]
[Date.]

Accepted. [Signature of person to whom rights are transferred.]

F. D. THOMSON,
Acting Clerk of the Executive Council.