Form No. 41.

Whereas, at a sitting of the Court holden at, on the day of, 189, of, being present in Court, and being required by me,, to give evidence in the said matter, did refuse to be sworn [or to give evidence in the said matter]: And whereas the said has been afforded opportunity to show cause why he should not be fined, and has failed to satisfy me, the said page 54: Now, I, the said, do hereby adjudge the said, for his said refusal, to forfeit and pay the sum of, to be paid and applied according to law; and, if the said sum be not paid forthwith, I,, adjudge the said to be imprisoned in the common gaol at, in the Provincial District of, for the space of, unless the said sum shall be sooner paid.