JULY 7.] THE NEW ZEALAND GAZETTE. 2207

Form No. 4.

National Provident Fund Act, 1926.

REQUISITION TO PAY MONEYS OUT OF FUND.

National Provident Fund,
, 192 .

The Public Trustee.

REQUISITION is hereby made to pay to the sum of £ for the purpose of the National Provident Fund Act, 1926.

, Superintendent of the Fund.

SECOND SCHEDULE.

Form No. 1.

National Provident Fund Act, 1926.

APPLICATION TO BECOME CONTRIBUTOR TO FUND.

To the Superintendent of the Fund.

I HEREBY apply 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 [in full] :

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 :

Is first contribution paid ?

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 of contributor or person signing on behalf of contributor.]

Date : , 192 .

If the contributions are to be paid by a parent, guardian, employer, or other person on behalf of the contributor, state hereunder the name and address of the same. If the contributions are partially paid by each, state in what proportions.

Enrolled by

Form No. 2.

National Provident Fund Act, 1926.

COMMUTATION TABLE.

Term of Years of Commutation. Lump Sum to commute Contribution of 1s. per week.
£ s. d.
43 .. .. .. .. 58 7 0
42 .. .. .. .. 57 15 0
41 .. .. .. .. 57 3 0
40 .. .. .. .. 56 10 0
39 .. .. .. .. 55 16 0
38 .. .. .. .. 55 3 0
37 .. .. .. .. 54 8 0
36 .. .. .. .. 53 13 0
35 .. .. .. .. 52 18 0
34 .. .. .. .. 52 2 0
33 .. .. .. .. 51 6 0
32 .. .. .. .. 50 9 0
31 .. .. .. .. 49 11 0
30 .. .. .. .. 48 13 0
29 .. .. .. .. 47 14 0
28 .. .. .. .. 46 15 0
27 .. .. .. .. 45 14 0
26 .. .. .. .. 44 14 0
25 .. .. .. .. 43 12 0
24 .. .. .. .. 42 10 0
23 .. .. .. .. 41 6 0
22 .. .. .. .. 40 2 0
21 .. .. .. .. 38 18 0
20 .. .. .. .. 37 12 0
19 .. .. .. .. 36 5 0
18 .. .. .. .. 34 18 0
17 .. .. .. .. 33 9 0
16 .. .. .. .. 32 0 0
15 .. .. .. .. 30 9 0
14 .. .. .. .. 28 18 0
13 .. .. .. .. 27 5 0
12 .. .. .. .. 25 11 0
11 .. .. .. .. 23 16 0
10 .. .. .. .. 22 0 0
9 .. .. .. .. 20 2 0
8 .. .. .. .. 18 4 0
7 .. .. .. .. 16 3 0
6 .. .. .. .. 14 2 0
5 .. .. .. .. 11 19 0

N.B.—Intermediate terms to be proportionate.

Form No. 3.

Contract No. .

National Provident Fund Act, 1926.

FORM OF ELECTION TO INCREASE (OR REDUCE) RATE OF CONTRIBUTIONS.

To the Superintendent of the Fund.

I [Name in full], being a contributor to the National Provident Fund, hereby elect to increase [or reduce] the rate of my weekly contribution to that Fund to , so as to increase [or reduce] my pension to a week.

[Signature.]

Date : ---

Form No. 4.

Contract No. .

National Provident Fund Act, 1926.

FORM OF ELECTION TO CEASE TO BE A CONTRIBUTOR.

To the Superintendent of the Fund.

I [Name in full], being a contributor to the National Provident Fund, hereby formally give notice that I elect to cease to be a contributor to the said Fund.

[Signature.]

Date : ---

Form No. 5.

National Provident Fund Act, 1926.

NOTICE OF CESSATION OF PAYMENT OF CONTRIBUTIONS BY EMPLOYER.

To the Superintendent of the Fund.

NOTICE is hereby given that contributions to the Fund on behalf of [Name in full] will cease to be paid by me on his behalf as from the day of , 19 .

[Signature of employer.]

Form No. 6.

National Provident Fund Act, 1926.

APPLICATION BY CONTRIBUTOR FOR MATERNITY BENEFIT.

To the Superintendent of the Fund.

, 192 .

Contract No. :

Name of claimant [in full] :

Residence :

Office where payment to be made :

Date of birth of child [Day, month, year ].

Sex of child :

Place of birth :

Christian name of child :

Name of medical attendant (if any) :*

Name of nurse :

Date and amount of last two payments of contributions to the fund—Date : . Amount : £ .

I HEREBY claim for medical attendance in respect of the birth of the above child the sum of £6.

[Signature of claimant.]

If “still-birth” or “miscarriage,” state particulars, including duration of pregnancy.

[Signature of medical attendant.]

“A.”

STATUTORY DECLARATION.

(Free of stamp duty.)

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 the birth of the above-mentioned child.

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 , 192 , before me—

Justice of the Peace [or Solicitor of the Supreme Court, or other person authorized to receive statutory declarations.]

• If no medical attendant, name of midwife.