Mar. 9.] THE NEW ZEALAND GAZETTE. 405

I agree to pay on demand the Office Solicitor’s costs and any other costs and expenses, whether the transaction be completed or not, and to insure all buildings on the property in the Superintendent’s official name as mortgagee if a loan is granted.

[Signature of applicant.]
[Occupation.]
[Address.]

1. (a) Have you previously applied to the Department for a loan; and, if so, when?
   (b) Have your or your wife (husband) or any member of your family at any time owned a property on which there was a State Advances loan; and, if so, state particulars?
   (c) Have you or your wife (husband) at any time owned a property mortgaged to another Government Department; and, if so, state particulars?
2. What is amount of loan required (maximum, £1,250) : £
3. (a) State amount paid off the section:
   (b) State amount you can find towards the cost of erecting the house:
4. (a) Are you married? . State age:
   (b) If about to be married, state when:
5. Is the land freehold or leasehold?
6. If leasehold, what is the class of lease (see para. 1 of pamphlet):
7. Description of property:—
   (a) No. of section, allotment, and Block No.:
   (b) Name of road, street, and local or survey district:
   (c) Distance from nearest railway-station, tram, or bus (state which):
8. Measurement of frontage to street or road: . Depth of land: . Area:
9. State from whom you acquired (are acquiring) the land: . Date of purchase:
10. State what public services, such as water, sewerage, electricity, or gas, are available:
11. Where are the title deeds to be obtained?
12. State name of builder:
13. What improvements other than the dwelling will be effected? Which of these (if any) are included in the tender?
14. State annual amount of rates or other charges (exclusive of rent) to which the property is liable:
15. Sketch-plan showing the boundaries of the land must be supplied hereunder.

Statutory Declaration.

(Where the applicant is married the Declaration must be made by both husband and wife.)

I (we), , of , do (jointly and severally) solemnly and sincerely declare:—

1. That, subject to the provisions of the State Advances Act, 1913, (relating to Advances to Workers) I (we) desire a loan for the sole purpose of erecting a home for myself (ourselves) and my (our) family.
2. That the replies to the questions in my (our) application for a loan are true and correct to the best of my (our) knowledge and belief.
3. That the land on which the proposed dwellinghouse is to be erected is to cost me (us) £ .
4. That the said proposed dwellinghouse is to cost me (us) £ .
5. That the proposed improvements—namely, to be effected are to cost me (us) £ .
6. That I, the said [Fill in husband’s full name] am employed as by and my weekly wages are £ .
7. That I am (we are) in receipt of an annual income of pounds.
8. That there are dependent on me (us) children or other persons [State names and ages].
9. That I am (we are) not the owner (owners) of any land other than the land which I (we) offer as security for the loan for which application is made.
10. That I am (we are) over twenty-one years of age.
11. That I (we) will forthwith, on completion of the dwellinghouse as aforesaid, reside permanently on the property.

And I (we), (jointly and severally), make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1927.

[Signature of husband.]
[Signature of wife.]

(Severally) declared at , this day of , 19 , before me— , A Justice of the Peace (or Solicitor).