Public Works.

A.—sc

THIRD SCHEDULE. Form A. For Cases where Lands are taken. Form op Claim to Compensation under " The Public Works Act, 1905." To [Here insert either the Minister for Public Works or the name of the local authority, as the case may be]. Whereas by a Proclamation by His Excellency the Governor, dated the day of ,19 , the lands mentioned in Table A hereunder, in which I have an interest as described in Table B hereunder, have been taken and vested in His Majesty for the purposes of [Here insert the name of the public work mentioned in the Proclamation] : And whereas the lands mentioned in Table C below, adjacent to the lands so taken, in which I have an interest as described in Table D below, will be injuriously affected by the said work by reason that [Here state items of claim, with a reference number to each, and give in each case full particulars of the nature and extent of claim] : This is to give notice that I claim the sum of £ as compensation for all loss arising out of the taking of the aforesaid lands and the construction of the said public work, which sum is made up as follows : —

1894, No. 42, Second Schedule. Section'l43.

Given under my hand this day of , 19 Claimant: [Christian name and surname in full. \ Address : [Address in full.]

TABLE A. Description op Lands taken. [Here describe the area and situation of lands taken, giving name of survey district, and number of block and section, as in Proclamation^)

TABLE B. Nature op Interest in Lands taken. [Here state in full the nature of the interest — as owner in fee-simple, mortgagee, lessee, or occupier ; and if the lands are leased or encumbered, or subject to any easement, give particulars of such lease or encumbrance, &c, &c]

TABLE C. Description of Lands injuriously affected. [Here describe the area and situation of the lands injuriously affected, giving name of survey district, and number of block and section, or other means of identification.]

TABLE D. Nature of Interest in Lands injuriously affected. \Here state in full the nature of the interest — as owner in fee-sample, mortgagee, les'ee, or occupier ; and if the lands are leased or encumbered, or subject to any easement, give particulars of such lease or encumbrance, &c, <&c]

12—A. sc.

89

9. d. acre:- roods perches of land taken, it per acre Land injuriously affected as follows: [Here state reference lumber and short heading of each item of claim previously detailed, md the amount claimed in respect of each such item separately.] Total claim .. .. .. £