Declaration under the Deferred-payment System.

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.
2.	I am making the present selection of land [or I am desirous of becoming the transferee of a license for land held by____, of____, under page 44 the system of deferred payments, under "The Land Act, 1885," and its amendments, bonâ fide for my own exclusive use and benefit, and not directly or indirectly for the use or benefit of any other person whomsoever, and for the purpose of cultivation.
3.	I have not at any time acquired the freehold of any land under the deferred-payment system, or under the homestead system, which with my present application, will exceed 640 acres in all.
4.	I am not the holder, either in my own name or in the name of any other person, of, and I am not beneficially interested in, any lands of the Crown within the colony under the deferred-payment system, or under the perpetual lease system, or under any agricultural lease to an amount which, added to the acreage comprised in this present application, would exceed 640 acres in extent.
5.	I am not the owner of a pre-emptive right, or of 640 acres of land in all.

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 Justice of the Peace Act, 1882."

A.B.