Form No. 44.

In the matter of "The Native Land Court Act, 1894," and of an application by, under section 65 of the Act, in respect of the cost of survey of [Describe land in respect of which costs incurred].

At a sitting of the Native Land Court held at, on the day of, 189, before, Esq., a Judge of the said Court:

Whereas it has been certified to the Court, in terms of section 65 of the said Act, that [as in certificate, Form No. 46]: And whereas it appears to the Court that [name and description] is the person entitled to receive payment of the moneys certified to be due as aforesaid, and that the same are still due and owing to the said: Now, therefore, it is hereby ordered that all that parcel of land containing [Describe land with sufficient certainty], do stand charged by way of mortgage, and the same is hereby charged accordingly, with the payment to the said, his executors, administrators, or assigns, of the said sum of ?, together with the further sum of £ for interest thereon [or that all that parcel of land (Describe as above) be, and the same hereby is, vested in the said in fee-simple, in satisfaction and discharge of such cost of survey].