Declaration under the Perpetual-lease System on taking a Lease or becoming the Transferee or Sublessee oe a Lease.

I, A.B., of [Insert place of abode and occupation], do solemnly and sincerely declare as follows :—

1.	I am of the age of seventeen years and upwards.page 39
2.	I am the person who, subject to the provisions of "The Land Act, 1885, and its amendments, am applying for the lease [or is desirous of becoming the transferee or sub-lessee of a lease] of section, Block, District.
3.	I am applying for [or I have purchased the interest of, of, in] a perpetual lease of the said section [or I have taken a sub-lease from, of, of the said section] for a term of years, to be computed from the day of, solely for my own use or benefit, and for the purposes of cultivation, and not directly or indirectly, for the use or benefit, of any other person whomsoever.
4.	Including the said lands, 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 640 acres [or if including second-class lands selected under "The and Act Amendment Act, 1887" 2,000 acres].
5.	I have not, within three years prior to the date hereof, surrendered a lease granted under "The Land Act, 1885," or its amendments with perpetual right of renewal of the lands for a lease whereof I am now applying.

And I make this solemn declaration conscientiously 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.

Taken and declared at____, this____day of____,18__, before me,____, a Justice of the Peace for the Colony of New Zealand.