H.—l.

SCHEDULE IV. Form op Experience Return.

" Friendly Societies Act, 1882."

Betukn of Sickness, Mortality, and other Contingencies experienced during the Year ended 31st December, 188^, by the , and of the Ages of Members at the Close of the Year. (Established in the Year 18 . Situated at .) Instructions. Particulars to be entered. 1. This form is to be filled up and returned to the Registrar of Friendly Societies, Wellington, on or before the Ist day of April next. No entry need be made of any members except such as have, during the year, either received sick-pay or other benefits, died, or otherwise left the , or married (if thereby entitled to a funeral benefit in event of wife's death), or whose wives have died during the year. Sickness. 2. The names of all members who received sick-pay during any portion of the year are to be entered first, in alphabetical order, in column 1; the period of sickness at each rate of sick-pay being entered in column 2, the rate in column 3, and the amount of sick-pay in column 4. If a member has received sick-pay at more than one rate, a separate line is to be taken for each rate, but the name is to be entered once only. In the same way, if a member has declared on the funds more than once during the year, a separate line is to be taken for each attack, but the name is to be entered once only. Registered wives. 3. The names of all members who married during the year (if thereby entitled to a funeral benefit in event of wife's death) are to be entered next in column 1. The letter Risto be inserted opposite their names in column 5, and the date of the wife's birth may be entered in column 6. Deaths. 4. The names of members who died or whose wives died during the year are to be entered next in column 1, the date of death being placed in column 7, the cause in column 8, and, where the entry refers to the death of a wife, the letter W in column 10. Members leaving. 5. The names of members leaving from any other cause than death are to be placed last in column 1, the date of leaving being entered in column 7, and the cause in column 9. Columns to be added. 6. The figures in columns 2 and 4 are to be added, and the total of the latter column must agree with the amount entered under the same head in the " General Statement of Eeceipts and Expenditure, Funds, and Effects." Remarks. 7. Particulars respecting any member not provided for in the earlier columns, but which it appears desirable to place on record, are to be entered in column 10 as Remarks. Ages of members. 8. The number of benefit members under 20 years of age on the 31st December is to be entered in line (1), on page 8, the number between 20 and 25 years of age in line (2), and so on, care being taken that the total so obtained agrees with the total as given in the " General Statement of Receipts and Expenditure, Funds, and Effects."

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Pahtici TO SlCKl JLAIiS RELATING IESS DUBING THE YEAE. Paetic BELATIi liEGISTI OP Wi ILAES (G TO ATION VES. PABTIc TO ME1 DUE :ulars n: Di-:athk [BEKS LEj tNG THE ' ELATING AND LVING ?EAE. (10.) Membees who have received Sick-pay or other Benefits, who have married (if thereby entitled to a Funeral Benefit in event of Wife's Deatli),who have died, or whose Wives have died, or who have left during the Year. (2.) 15 I si ■s 1 Sic! (3.) Is Pay. (4.) (5.) Q a fcJD a ■5 s ® § "So ti E o (0.) (7.) a £ i I (ft) s» IP en en O ft d^ lei ataH I ■3 ® Q ft O i 'i-i |3 a O of s« Q (1.) (8.) Name. Cause. Wks. dys. £ s. a. Carried forward