JULY 7.] THE NEW ZEALAND GAZETTE. 2209

THIRD SCHEDULE.

Form No. 1.

National Provident Fund Act, 1926.

SUPERANNUATION.—FORM OF APPLICATION TO BECOME A CONTRIBUTOR.

APPLICATION is hereby made by the __ to become a contributor to the National Provident Fund on behalf of all* the following employees :—

Total staff :

Total number proposed to be entered in fund :

Age at which pension payable :

[SEAL.] [Signature.]

Date :

| Identifica- | Name (in | Sex. | Occupa- | Date | Date of | Rate of | Other |
| tion No. | full) of | | tion. | of | com- | Salary | Particu- |
| (For use of | Person. | | | Birth. | mencing | or | lars. |
| National | (Surname | | | | Service.| Wages. | |
| Provident | first.) | | | | | | |
| Fund | | | | | | | |
| Office.) | | | | | | | |

• If whole staff is not included the word “all” should be struck out.

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Form No. 2.

National Provident Fund Act, 1926.

SUPERANNUATION.—FORM OF ELECTION TO INCREASE OR REDUCE RATE.

To the Superintendent of the Fund.

THE __, being a contributor to the National Provident Fund on behalf of the undermentioned persons, hereby notifies that the rates of the salaries thereof are increased [or reduced] as set out hereunder, so as to increase [or reduce] the pension rates accordingly.

, Mayor or Chairman of Local Authority.

Date :

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Form No. 3.

National Provident Fund Act, 1926.

SUPERANNUATION.—NOTICE OF CESSATION OF EMPLOYMENT.

To the Superintendent of the Fund.

IT is hereby notified that __ will cease his employment with __ as from the __.

He has decided—

(1) That his contributions be refunded forthwith in terms of section 28 (1) of the Act.

(2) To apply to the National Provident Fund Board to be accepted as a contributor to the Fund, and to allot these contributions thereto.

(3) To leave his contributions in the Fund for the period of eighteen months specified in section 28 (3) and (4) of the Act, in order that the contributions may be transferred to his credit should he become an employee of a local authority contributor to the Fund under this Act.

[Strike out the options the employee rejects.]

Signature of employee :

Private address :

ALLOCATION OF CONTRIBUTIONS FOR REFUND.

Employee .. £ : :

Employer .. £ : :

Total .. £ : :

Including .. £ : : in transit

Signed [Official of local authority].

Date :

N.B.—This notice must be sent to the Superintendent as soon as possible before the date of leaving in order that the refund, if desired under (1), may be authorized promptly.

Form No. 4.

National Provident Fund Act, 1926.

SUPERANNUATION.—NOTICE OF RETIREMENT.

Employee’s name [in full] :

Occupation :

Name of local authority, employer, &c. :

Place :

Postal address :

Date of commencement of service :

Cause of retirement :

Date of retirement [last working-day] :

Annual rate of salary payable as at [Date three years prior to date of retirement] : £ : :

If employee retiring by reason of infirmity, state—

(a) If you have any reason to believe that such state has been caused by irregular or intemperate habits :

(b) If he is suited for any other employment in the service of the local authority, and, if so, of what nature :

I hereby certify that to the best of my knowledge and belief the above particulars are true and correct in every respect.

[Signature.]

Mayor or Chairman of Local Authority.

Date : , 192 .

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Form No. 5.

National Provident Fund Act, 1926.

SUPERANNUATION.—APPLICATION FOR WIDOW AND CHILDREN’S ALLOWANCE.

To the Superintendent of the Fund.

I, __, the widow of __, who at his death was a contributor to the National Provident Fund through the __, hereby claim an allowance representing £18 per annum as his widow or a refund of all contributions paid on his behalf,* and 5s. per week for __ of his children under fourteen years of age.

I attach herewith the following documents :—

(1) Certificate of death of contributor.

(2) Marriage-certificate.

(3) Birth-certificate of children under age fourteen.

[Signature of widow.]

Address :

Date :

• Strike out the option which the claimant rejects.

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Form No. 6.

National Provident Fund Act, 1926.

SUPERANNUATION.—APPLICATION OF A PERSON IN A LOCAL AUTHORITY’S EMPLOY TO PAY AMOUNT TO A FRIENDLY SOCIETY.

I, __, hereby apply to have the amount of __ per week out of the deductions made from my wages by the __ paid to __ friendly society at __ for the Sick and Funeral Fund thereof, the benefits therefrom to be regarded as benefits of the National Provident Fund in respect of incapacity and death.

[Signature of applicant.]

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Form No. 7.

National Provident Fund Act, 1926.

SUPERANNUATION.

RETURN OF CONTRIBUTIONS paid to the Fund on behalf of Employees (including Employer’s Proportion) for the Calendar Month ending __, 192 , by the __.

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Form No. 8.

National Provident Fund Act, 1926.

SUPERANNUATION.—DECLARATION AS TO CONSTITUTION OF STAFFS AND THE CORRECTNESS OF AMOUNTS PAID ON BEHALF OF EMPLOYEES TO THE FUND.

I [Name and official designation], do hereby solemnly and sincerely declare that the annexed statement entitled “Return of Contributions paid to the Fund on behalf of Employees” for the __ month ending __, 19 , by the [Name of employer], is true and correct in every particular, and that the said statement contains the names of all employees permanently appointed to the staff since the date of the last declaration.