776
THE NEW ZEALAND GAZETTE.
[No. 22

FORM No. 15.
DECLARATION AND INFORMATION REQUIRED IN SUPPORT OF
AN APPLICATION FOR REFUND OF TAX UNDER SECTION 37
OF THE FINANCE ACT, 1917.

Name of Applicant [Surname, Christian name, and address].
Particulars for the Year ended 31st March, 19 .

8. The amount of income derived by me from all sources, whether in New Zealand or elsewhere, during the above year was £ .

I, the person furnishing the above information, do solemnly and sincerely declare that the particulars written above are true and correct and contain all the information known to me in connection with the matters inquired into ; and I make this declaration under the provisions of the Land and Income Tax Act, 1916, and its amendments.

Signed at , this day of , 19 .
[Usual signature.]

———

FORM No. 16.
Land and Income Tax Act, 1916, and the Justices of the Peace Act, 1908.

FORM OF DECLARATION TO ENABLE DEBENTURE-HOLDERS WHOSE HOME IS IN NEW ZEALAND, AND WHOSE TOTAL INCOME FROM ALL SOURCES DOES NOT EXCEED £300, TO RECEIVE PAYMENT OF THE INTEREST WITHOUT DEDUCTION FOR INCOME-TAX.

I, , of [Insert place of abode and occupation], being the holder of debentures numbered , issued by , do solemnly and sincerely declare that—

1. My home is in New Zealand.
2. My total income from all sources does not exceed £300.

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.]

Declared at , this day of , 19 , before me—

Justice of the Peace
[or Solicitor, or Notary Public].

Noted by [Local Authority].

———

FORM No. 17.
Land and Income Tax Act, 1916, and Amendments, and the Justices of the Peace Act, 1908.

FORM OF DECLARATION TO ENABLE SOCIETIES, TRUSTS, INSTITUTIONS, AND OTHER BODIES, WHOSE INCOMES ARE EXEMPTED FROM TAXATION BY SECTION 84 OF THE LAND AND INCOME TAX ACT, 1916, TO RECEIVE PAYMENT OF INTEREST ON DEBENTURES WITHOUT DEDUCTION FOR INCOME-TAX.

I, , of [Insert place of abode and occupation], being the holder of debentures numbered , issued by , do solemnly and sincerely declare that—

1. The interest payable in respect of the debenture investment is the income of the [Insert name of society, trust, or institution].
2. Under the provisions of section 84 of the Land and Income Tax Act, 1916, the said income is exempt from income-tax.

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.]

Declared at , this day of , 19 , before me—

Justice of the Peace
[or Solicitor, or Notary Public].

Noted by [Local Authority].

———

FORM No. 18.
Land and Income Tax Act, 1916, and Amendments.
CERTIFICATE OF DEDUCTION OF INCOME-TAX.

I HEREBY certify that, on paying to [Surname, Christian name, occupation, and address], the sum mentioned in the first column of the subjoined statement, I deducted for income-tax the amount set forth in the second column of the said statement.

[Place and date.]

[Signature.]

———

FORM No. 19.
Land and Income-tax Act, 1916, and the Justices of the Peace Act, 1908.

FORM OF DECLARATION AS TO TOTAL INCOME FROM ALL SOURCES.

I, , of [Insert place of abode and Occupation], do solemnly and sincerely declare that my total income from all sources (whether assessable or not) does not exceed £2,000.

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.]

Declared at this day of 19 , before me—

Justice of the Peace
[or Solicitor, or Notary Public].

———

FORM No. 20.
CERTIFICATE OF PAYMENT OF INCOME-TAX.
DOMINION OF NEW ZEALAND.

Particulars of Tax charged and paid for the Financial Year ended 31st March, 19 .

Name of taxpayer :
Assessment :—
Taxable amount : £ .
Rate of tax : in the pound.
Amount of tax .. .. .. £
20 per cent. additional tax .. .. .. £
Total .. .. .. £
Less 10 per cent. for earned income .. .. £
Total tax paid .. .. .. £

I certify that the above particulars are correct.

Commissioner of Taxes for the Dominion of New Zealand.

Wellington, New Zealand, , 19 .

———

FORM No. 21.
Land and Income Tax Act, 1916, and Amendments.

STATUTORY DECLARATION IN SUPPORT OF APPLICATION FOR EXEMPTION UNDER SECTION 16 OF THE FINANCE ACT, 1917.

I, of , do solemnly and sincerely declare :—

1. That, on the day of , 19 , I agreed to sell, and , of , agreed to purchase, the land described in the Schedule hereto.
2. That the said agreement has been duly executed and is still in force.
3. That possession of the said land has been delivered by me to the said purchaser on the day of , 19 , in pursuance of the said agreement, and that he is still in possession of the same.
4. That the total purchase-money under the said agreement is £ , and that the sum of £ , being part thereof, has been paid to me by the said purchaser in pursuance of the said agreement.
5. That no money has been lent by me, directly or indirectly, to the said purchaser and is still unpaid.
6. That no liability of the said purchaser is directly or indirectly guaranteed by me.
7. That no money other than the said purchase-money is owing to me on the security of the said land.

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.]

Declared at , this day of , 19 , before me—

Justice of the Peace
[or Solicitor, or Notary Public].