Form
Declaration on applying for a Lease under Part III.

I. A.B., do most solemnly and sincerely declare—

1.	That I am of the age of seventeen years and upwards.
2.	That I am the person who, subject to the provisions of "The Native Reserves Administration Act, 1893," am applying for the purchase [or am desirous of becoming the transferee or sub-lessee] of a lease of all that [Here describe the land with sufficient particularity to identify it.]
3.	That I am acquiring: such lease solely for my own use and benefit, and not directly or indirectly for the use or benefit of any other person or persons whomsoever.
4.	That, including the lands now applied for, I am not the owner tenant, or occupier, directly or indirectly, either by myself or jointly with any other person or persons, of any lands anywhere in the colony exceeding in the whole 2,000 acres of land, inclusive of not more than 640 acres of first-class land.
5.	That I have not, within one year from the date hereof, surrendered a lease of lands under the above-mentioned Act for a lease whereof I am now applying.

And I make this solemn declaration concientiously believing the same to be true, and by virtue of an Act of the General Assembly of New Zealand intituled "The Justices of the Peace Act, 1882."

A.B.

Declared at, this day of, 189, before me, a Justice of the Peace in and for the Colony of New Zealand.