Form No. 32, Rule 69.—Certificate of Surveyor General.

In the matter of the survey of the land known as situate at

I, the undersigned, hereby certify, within the terms of the 81st section of "The Native Land Court Act, 1886," that the sum of £_____, is owing by Natives to_____, a certified surveyor, for the plan numbered_____, of the said land or [and] for the survey on which the said plan was founded Dated this_____, day of_____, 189.

[An officer authorised by the] Surveys General [in that behalf].