2208
THE NEW ZEALAND GAZETTE.
[No. 46

Form No. 7.
National Provident Fund Act, 1926.
APPLICATION FOR INCAPACITY ALLOWANCE.

To the Superintendent of the Fund.
I [Name in full], of [Address and occupation], a continuous contributor to the National Provident Fund, hereby claim a weekly allowance of £ : : , representing 7s. 6d. per week for of my children under fourteen years of age, on the ground that I have been wholly incapacitated from carrying on my trade [business, employment, calling, or occupation] for more than three months, and am still wholly incapacitated.
I attach hereto (1) certificate of medical attendant, (2) marriage-certificate, (3) birth-certificates of children. [If married in New Zealand or children born in New Zealand and certificates not readily available, the particulars below must be filled in for verification purposes.]

Names, Places, and Dates of Birth of Children.

Place and Date of Marriage.

I declare the following particulars to be true and correct to the best of my knowledge and belief:—

1. Cause and nature of total incapacity:
2. Date of commencement of total incapacity:
3. If recovered, state date when first able to resume some portion of usual business or occupation:
4. Where last employed:
5. If incapacity arose out of accident, give date and full particulars of such accident:
6. If incapacity arose out of an illness, give date of original commencement of such illness:
7. Is the incapacity due to your serious misconduct:
8. On what date were you discharged from war service?
9. What was your weekly gross income immediately prior to commencement of total incapacity?
10. State total gross income per week received or due during total incapacity as follows:—

Total gross income per week £ : :

And I also declare 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.

[Signature of Contributor.]

Date: .
Address: .
An answer must be given to every question.

——

Form No. 8.
National Provident Fund Act, 1926.
APPLICATION FOR WARRANT TO RECEIVE ALLOWANCE.

I, , hereby request that a warrant be issued authorizing to receive allowances due to me from the National Provident Fund, as I am unable to attend at a paying-office owing to .

[Signature of contributor.]

I assent—[Signature of agent.]
Date: .

Form No. 9.
National Provident Fund Act, 1926.
WARRANT TO RECEIVE ALLOWANCES.

THIS warrant authorizes , of , to receive the allowances due to from the National Provident Fund.
, Superintendent of Fund.

Wellington,
Date: .

——

Form No. 10.
National Provident Fund Act, 1926.
APPLICATION FOR CHILDREN’S ALLOWANCE.

To the Superintendent of the Fund.
I, , the widow of , who at his death was a continuous contributor to the National Provident Fund, hereby claim a weekly allowance of £ : : , representing 7s. 6d. per week for of his children under fourteen years of age, and 7s. 6d. per week as his widow.
I attach herewith the following documents:—
(1) Certificate of death of contributor.
(2) Marriage-certificate.
(3) Birth-certificates of children.
I declare that the contributor had not, since becoming 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.

[Signature of widow.]

Address: .
Date: .

——

Form No. 11.
National Provident Fund Act, 1926.
FORM OF DECLARATION AS TO IDENTITY OF DECEASED CONTRIBUTOR TO THE FUND MADE BY SOME RESPONSIBLE PERSON OTHER THAN CLAIMANT.

(Exempt from stamp duty.)

I [Name in full], of [Address and occupation], in the Dominion of New Zealand, hereby solemnly and sincerely declare:—
That during his lifetime I knew and was well acquainted with [Full name of deceased contributor], of [Residence], who died at [Place of death], in the said Dominion, on the day of , 192 , and I had reason to believe that the said deceased was a contributor to the National Provident Fund, because [State generally any circumstances to show how the declarant became acquainted with the facts stated].
That I also know [Name of claimant], the [Relationship to deceased] of the said deceased, and who is now the claimant for allowances from the said fund.
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,——

A Justice of the Peace for the Dominion of New Zealand, [or Solicitor, or other person authorized to receive statutory declarations].

——

Form No. 12.
National Provident Fund Act, 1926.
TRANSFER.

I [or We], , do hereby transfer all rights in respect of Contract No. , made on , under sections 62 or 63 of the National Provident Fund Act, 1926, to and in favour of , the person on behalf of whom the aforesaid contract was made.

Signature of contributor:
On behalf of:
Date:
Accepted — [Signature of person to whom rights are transferred.]
Signature of witness:
Occupation:
Address: