2210
THE NEW ZEALAND GAZETTE
[No. 46

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1908.

Declared at this day of , 19 , before me—
Justice of the Peace [or Solicitor, or other person authorized to receive statutory declarations].
[To be furnished quarterly.]

FOURTH SCHEDULE.
Form No. 1.
National Provident Fund Act, 1926.
MATERNITY ALLOWANCE FOR MEMBERS OF FRIENDLY SOCIETIES.

To the Secretary.
I HEREBY request that the maternity allowance payable to my wife in respect of the birth of a child, as certified below, should be paid.
[Signature of member.]

1. Name of society and branch :
2. Christian name of child :
3. Date of birth of child [day, month, year] :
4. Place of birth of child :
5. Did the joint income of yourself and your wife during the twelve months immediately preceding the date of birth of the child exceed £300 ?
6. Was your wife resident in New Zealand at the time of the birth of the child ?
7. Are you claiming a maternity allowance in respect of this birth from another friendly society or from the National Provident Fund as a contributor thereto ?

DECLARATION.
(Free of stamp duty.)
I [Name in full], of , do solemnly and sincerely declare that the above statements are true and correct in every particular, 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 the wife wishes to authorize the payment of the allowance to her husband, she must sign the following form of authority.]
I hereby authorize the payment of this allowance to my husband [Insert husband’s name in full].
[Wife’s signature.]

CERTIFICATE.
I HEREBY certify that [Name in full] gave birth to a child on , and was attended by me during her confinement.
Signed*:
Date :
If “Still birth” or “Miscarriage,” state particulars, including duration of pregnancy, such claims must be referred to the Superintendent before payment.
(For use of Branch.)

I HEREBY CERTIFY as follows:—

1. The claimant is a benefit member of the society.
2. The claimant had completed twelve months’ membership at the date of birth of the child.
3. The claimant was a financial member at that date.
4. The claim is properly filled in.
   [Signature of secretary.]

Date :
NOTED IN CENTRAL BODY’S BOOKS.
Date :
Initials :

RECEIPT FROM WIFE OR HUSBAND ON HER BEHALF (IF AUTHORIZED).
RECEIVED the sum of in cash.
Date :
[Signature.]

SECOND RECEIPT FROM WIFE OR HUSBAND ON HER BEHALF (IF AUTHORIZED).
(To be retained by Branch Secretary.)
RECEIVED the sum of in cash.
Date :
[Signature.]

• Add any qualifications. If the nurse or midwife is on the Health Department’s Register she should describe herself as “registered nurse” or “registered midwife.”

Form No. 2.
National Provident Fund Act, 1926.
APPLICATION FROM MEMBER OF FRIENDLY SOCIETY TO CONTRIBUTE.

To the Superintendent of the Fund.
I HEREBY apply through the Society 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 :
Date of birth : . Sex :
Place of birth :
Age last birthday :
Occupation :
Married or single :
If married woman or widow give maiden name :
Amount of contribution :
Amount of weekly pension required :
[Signature of member.]

Date : , 19 .
I hereby 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.]

Contributions amounting to £ : : received and interim receipt given for same.
[Signature of secretary.]

NATIONAL PROVIDENT FUND.—INTERIM PAY-IN-SLIP TO BE FORWARDED TO SUPERINTENDENT.

I HEREBY pay the sum of pounds shillings and pence, being the contributions to the above-named fund of*
Amount.
£ s. d.
[Signature of payer-in.]
[Signature of secretary.]

Date : . Name of branch and district : .

• State name of contributor.

Form No. 3.
NATIONAL PROVIDENT FUND.—INTERIM RECEIPT.

Name :
RECEIVED the sum of pounds shillings and pence.
£ : : .
Date : .
Name of Branch :
[Signature of secretary.]

The member will receive from the Superintendent a contribution-book, which must be used for all payments thereafter made.
(To be handed to member.)

NATIONAL PROVIDENT FUND.—BRANCH RECEIPT.

Name :
RECEIVED the sum of pounds shillings and pence.
£ : : .
Date : .
Name of branch :
[Signature of secretary.]

(To be retained by branch secretary.)

Form No. 4.
National Provident Fund Act, 1926.
APPROVED FRIENDLY SOCIETY.

Name of branch (and society) :
RETURN of pension contributions received by the above-named branch from members during the period to
Name :
Amount :
Date : , Secretary of Branch.

(For Central Body Use only.)

NOTED in society account.
[Signature of secretary of central body.]
[Date of entry.]