2858 THE NEW ZEALAND GAZETTE. [No. 82

I, the person replying to the foregoing questions, do
solemnly and sincerely declare that the answers 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, 1923.
Signed at , this day of , 19 .
[Usual signature.]

FORM No. 11.
Land and Income Tax Act, 1923.

STATUTORY DECLARATION IN SUPPORT OF APPLICATION FOR
EXEMPTION UNDER SECTION 61 OF THE LAND AND INCOME
TAX ACT, 1923.

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 pur-
   suance of the said agreement.
5. That no money has been lent by me, directly or in-
   directly, 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 believ-
   ing 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].

THE SCHEDULE ABOVE REFERRED TO.
ALL that parcel of land, containing by admeasurement
, and being .

FORM No. 12.
NOTICE OF CHANGE OF OWNERSHIP OF LAND FOR LAND-TAX
PURPOSES.

To the Commissioner of Taxes, Wellington.

REFERRING to the undermentioned land, at present assessed
in the name of [Surname, Christian name, occupation, address],
I hereby give you notice, pursuant to section 68 of the
Land and Income Tax Act, 1923, that I have ceased to be the
owner of the land, and that my successor in title is [Surname,
Christian name, occupation, and address].

I also hereby declare that the particulars hereinafter set
forth with respect to the said land are true and accurate :—

Date of sale or other disposition :
Date on which purchaser entered into possession :
Mode of disposition (e.g., sale, gift, or exchange, or as the
case may be) :
Amount of purchase-money .. .. £
Balance of purchase-money unpaid at noon on
31st March, 19 (if any) .. .. £
[Signature.]

FORM No. 13.
Land and Income Tax Act, 1923, 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 78 OF THE LAND
AND INCOME TAX ACT, 1923, 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 invest-
   ment is the income of the [Insert name of society, trust, or
   institution].
2. Under the provisions of section 78 of the Land and
   Income Tax Act, 1923, the said income is exempt from
   income-tax.
   And I make this solemn declaration conscientiously believ-
   ing 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. 14.
Land and Income Tax Act, 1923, 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 believ-
   ing 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. 15.
DECLARATION AND INFORMATION REQUIRED IN SUPPORT OF
AN APPLICATION FOR REFUND OF TAX UNDER SECTION 99
OF THE LAND AND INCOME TAX ACT, 1923.

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, 1923.
Signed at , this day of , 19 .
[Usual signature.]