Claim in respect of theft by a solicitor, or by a servant or agent of a solicitor
To the Council of the [specify]
New Zealand Law Society, Wellington
Take notice that I [we], [name in full], of [address in full and occupation], having suffered pecuniary loss by reason of the theft by [name in full], a solicitor (or, a servant or agent of [name in full] a solicitor) with respect to whom the Law Practitioners Act 1982 applies of [amount of money or description and value of other valuable property stolen] entrusted to the said solicitor (or to [name in full of servant or agent], the servant or agent of the said solicitor) in the course of his practice as a solicitor (or as a solicitor-trustee) hereby claim against the Solicitors' Fidelity Guarantee Fund established under the said Act for the sum of [amount] as reimbursement in respect of such loss.
Particulars of claim
[Here state full particulars of the matters by reason of which the claimant alleges that he is entitled to claim against the fund, setting out as fully as possible the history of dealings with the practitioner leading up to the claim, and giving copies of such letters, ledger accounts, statements, and other documents as are relevant.]
Particulars of amount of claim
[Here state full particulars of amount of claim.]
Dated at: [place, date]
Witness to signature—
Signature of witness:
Schedule form 1: amended, on 1 April 1983, pursuant to section 193(1) of the Law Practitioners Act 1982 (1982 No 123).
Declaration by claimant desiring the Council to consider settlement of his claim
I [name in full], of [address in full and occupation], being desirous that the Council of the New Zealand Law Society shall consider the settlement of my claim against the Solicitors' Fidelity Guarantee Fund, hereby solemnly and sincerely declare that the particulars given by me in the notice to the said Council (which notice is annexed hereto and marked
“A”) are a full and true statement of the facts concerning my claim.
And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act 1927.
Declared at [place, date].
Signature of declarant:
(Solicitor or Justice of the Peace)