To the Council of the New Zealand Society of Accountants, Wellington.
Take notice that I (we), [name in full], of [address in full and occupation], having suffered pecuniary loss by reason of the theft, embezzlement, or misappropriation by [name in full], a (public) accountant (or, a servant or agent of [name in full], a (public) accountant) with respect to whom Part 1 of the New Zealand Society of Accountants Amendment Act 1963 applies of [amount of money or description and value of other valuable property stolen] entrusted to the said (public) accountant (or to [name in full of servant or agent], the servant or agent of the said (public) accountant) hereby claim payment from the New Zealand Society of Accountants Fidelity Fund established by section 4 of the said Act of the sum of [amount] pounds [amount] shillings and [amount] pence as reimbursement in respect of that 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]
Signature of witness:
I [name in full], of [address in full and occupation], hereby solemnly and sincerely declare:
|*Delete whichever is inapplicable.|
And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Oaths and Declarations Act 1957.
Declared at: [place, date].
Signature of declarant:
(Solicitor or Justice of the Peace)
Dated at Wellington this 30th day of September 1964.
Thomas G Hull,
President of the New Zealand Society of Accountants.