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THE NEW ZEALAND GAZETTE.

PART E.
Income from Sales of Land or any Interest therein (including Houses or other Buildings erected on the Land) during the Year ended , 19 .

Sales of land during the year : [Area], sold for Land unsold at end of year at cost price, plus improvements : [Area], valued at

Less land held at beginning of year at cost price, plus improvements : [Area], valued at Purchases of land during the year : [Area], bought for
Expenditure during the year on improvements : [Specify nature of improvements]

Gross income ...
Less other expenses incurred during the year, namely :—

Net income ... £

PART F.
Statement of Receipts and Expenditure in respect of Properties let* or Royalties derived from Land during the Year ended on 31st March, 1925.

Receipts. £
Rental received from houses*
Rental received from farming property let to [State names and addresses of tenants]
Rental received from business premises
Rental received from other sources
Royalties [Specify] ..
Total £

Expenditure. £
Rates ...
Ground rent paid in respect of lease [State name and address of person to whom paid]
Insurance ...
Repairs and maintenance ...
Expenses of collection
Mortgage interest [State names and addresses of mortgagees and amount paid to each]
Other interest [State names and addresses of persons to whom money is owing and amount paid to each]
Net income from properties
Total £

• Including rental from subletting rooms and houses.

PART G.
Claims for Special Exemptions.

NOTE.—In the case of partnerships, the particulars in respect of each partner should be separately shown. These exemptions should not be entered in any other part of this form.

1. Amount actually paid by me during the year—
   (a.) As life-insurance premiums on my own life, for my own benefit or for the benefit of my wife and children .. ., .. £
   (b.) To Superannuation Fund .. .. .. £
   (c.) To National Provident Fund or insurance fund of friendly society .. .. £ [Specify name of fund here.]
   No. 12

2. Amount claimed in respect of my own* children under the age of eighteen years dependent on me, particulars of whom are given hereunder ... £
   NOTE.-If space hereunder is insufficient a separate sheet may be used. (£50 for each child.)

Name of Child. Place of Birth. Date of Birth.

• "Children" includes stepchildren and adopted children.

3. Amount contributed during the income year towards the support of my widowed mother £ Full name and address of widowed mother :

4. Five per cent. on the capital value of my interest, as shown on District Valuation Roll, in the land used in the production of the income shown in this return, namely :—

No. on District Valuation Roll. District, County, Borough, or Town Land situated. Block, Survey District Street, or Area. Reference to Locality. Purpose for which Land used. (Indicate whether used for business, letting, or other purpose.) Number of Months for which used. Capital Value (as shown on District Valuation Roll). A. R. P.

STATEMENT No. 1.-NAMES, ADDRESSES, AND SHARES OF PARTNERS.
[To be filled up in the case of returns made by or on account of a firm or partnership.]

Name in full of each Partner. Address. Amount credited to each Partner.
Salary (if any). Interest on Capital (if any). Share of Balance of Net Income. Total. £ £ £ £

• The amounts to which each partner is entitled should be shown in these columns, whether actually drawn or not. This total should agree with "Total net income" on Summary .. £

STATEMENT No. 2.-TRUSTEES' STATEMENT.
[To be filled up in case of a deceased person's estate or other trust.]

Name in full of each Beneficiary. Occupation. Place of Residence. Share of Assessable Income. £ *

• Please indicate in this column by "Yes" or "No" whether or not the beneficiary is entitled to demand his or her share of the income during the income year. This total should agree with "Total net income" on Summary .. £

PART H.
Return as Agent for Debenture-holders.
[To be filled in by companies and other corporate bodies which have issued debentures.]

Date when debentures issued : , 19 .
RETURN of the income of the debenture-holders received or receivable for the year ended the , 19 £