3

E.—lo

DECLARATION. I,' [Name], of [Place of abode], [Occupation], do solemnly and sincerely declare that I am Chairman [or Secretary, or Treasurer] of the [Name of institution] ; that during the year ending on the 31st day of December, 1914, the receipts of the aforesaid institution for the maintenance of tho library only were as follows : Prom rates levied by a local governing body under Part I of the Libraries and Mechanics' Institutes Act, 1908, or the Municipal Corporations Act, 1908, pounds shillings and pence : from the subscriptions of members, pounds shillings and pence ; and from voluntary contributions other than members' subscriptions, pounds shillings and pence ; that the library is public in the sense of belonging to the public, and is not under the control of an association, society, or club whose membership is composed of a section of the community only ; that the information hereinafter furnished by me in the appendix hereto is correct in every particular ; that the abstract of accounts is a true statement of the receipts and expenditure of the institution for the year herein specified ; that the whole of the subsidy received during the year was expended in the purchase of books for tho library ; [and that by the rules of the library it is open to the public free of charge]. 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.] Declared at , this day of , 191 , before me — , Justice of the Peace [or Solicitor, or Notary Public]. [Hero affix and cancel a stamp at 2s. 6d.] [Note. —The words relating to last year's subsidy and to free admission may be struck out if they are not applicable. The words in brackets are not part of the form, but indicate matter to be inserted or substituted.] 6. Copies of the form of application may be obtained from the Secretary for Education, Wellington, and from tho Secretary of any Education Board. James Allen, Minister of Education.