Nov. 22.] THE NEW ZEALAND GAZETTE. 2859

FORM No. 16.
Land and Income Tax Act, 1923.
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.]
Amount of Interest from
which I have deducted
the Tax.
£ s. d. £ s. d. Period to which
Amount of Income-tax the Interest
Numbers was due.
and Description
deducted by me. of
Debentures.
[Date.]
FORM No. 17.
Land and Income Tax Act, 1923, 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. 18.
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 . . . . . . £
Less 20 per centum thereof . . £
£
Less 10 per centum in respect of
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. 19.
The Land and Income Tax Act, 1923.
WARRANT TO NON-RESIDENT AGENT UNDER SECTION 109.
To
I, , the Commissioner of Taxes within the Dominion
of New Zealand [or Collector of Customs at , as the
case may be], in pursuance of the power conferred on me by
section 109 of the Land and Income Tax Act, 1923, do hereby
authorize you to act in New Zealand as a non-resident agent
for or on behalf of [Names, addresses, and lines of business of
principals].
This warrant shall continue in force for two months from
the date hereof, but may be revoked at any time before the
expiry of such period. You are respectfully requested to
forward this warrant to the Commissioner of Taxes at Wel-
lington prior to your departure from New Zealand.
Given under my hand at , this day of
, 19 .
Commissioner of Taxes [or Collector of Customs].
FORM No. 20.
The Land and Income Tax Act, 1923.
WARRANT TO NON-RESIDENT TRADER TO CARRY ON BUSINESS
IN NEW ZEALAND UNDER SECTION 109.
To
I, , the Commissioner of Taxes within the Dominion
of New Zealand [or Collector of Customs at , as the
case may be], in pursuance of the power conferred on me by
section 109 of the Land and Income Tax Act, 1923, do hereby
authorize you to carry on business in New Zealand as a non-
resident trader [Insert here address and line of business].
This warrant shall continue in force for two months from
the date hereof, but may be revoked at any time before the
expiry of such period. You are respectfully requested to for-
ward this warrant to the Commissioner of Taxes at Wellington
prior to your departure from New Zealand.
Given under my hand at , this day of
, 19
[Commissioner of Taxes or Collector of Customs].
FORM No. 21.
BOND.
The Land and Income Tax Act, 1923.
Know all men by these presents that I , of
(taxpayer), trading under the style and title of
and , of , and* , of
(sureties), are held and firmly bound unto our Sovereign
Lord King George the Fifth in the sum of sterling,
to be paid to our said Lord the King, his heirs and succes-
sors ; to which payment well and truly to be made we bind
ourselves and every of us, jointly and severally, for and
in the whole, our and every of our heirs, executors, and
administrators, firmly by these presents. Sealed with our
seals. Dated this† day of , one thousand
nine hundred and .
WHEREAS by the Land and Income Tax Act, 1923, it is pro-
vided that the Commissioner of Taxes may at any time and
from time to time require any non-resident trader or non-
resident agent to give security by way of bond, deposit, or
otherwise to the satisfaction of the Commissioner for the
payment of any income-tax which may become payable by
him ; and whereas it appears that the said hath pro-
posed to give the security of these presents for the due payment
of all income-tax which may become payable by him, and the
said Commissioner has agreed to accept such security : Now,
the condition of the above-written bond or obligation is such
that if the said shall, upon demand, make to the said
Commissioner such returns or statements as he (the said
Commissioner) may from time to time require, and shall also
pay to the said Commissioner all income-tax which under
the provisions of the said-recited Act and its amendments
or the regulations thereunder may be lawfully assessed or
levied upon him, then the above-written bond or obligation
shall be void, but otherwise shall be and remain in full force
and virtue.
[L.S.]
[LS.]
[LS.]
Signed, sealed, and deliverd by the above-named
in the presence of .

• Names, residences and occupations, in words at length, of taxpayer
  and of two sureties.
  † Date of first signature in words at length.
  FORM No. 22.
  RECEIPT FOR DEPOSIT.
  The Land and Income Tax Act, 1923.
  £
  RECEIVED from , of , the sum of £
  by way of deposit made pursuant to section 110 of the Land
  and Income Tax Act, 1923, as security for the due payment
  of income-tax on the profits derived from the business
  of .
  Such deposit to be returnable at the discretion of the
  Commissioner of Taxes.
  Commissioner of Taxes, Wellington.
  Dated this day of , 19 .
  Countersigned by , Collector of Customs [or
  Receiver of Land and Income Tax].
  FORM No. 23.
  LIST OF DEBENTURE-HOLDERS AT , 19 .
  And other Particulars required in Terms of Section 119 of the
  Land and Income Tax Act, 1923.
  Particulars of Debenture.
  Particulars of Debenture-holder.
  Debenture Name of Loan, Value Surname. Christian Occu-
  No. Date of Debenture, and Date Name. pation.
  Issue. and Date of Maturity. of Interest. Address.