Declaration.

I,___, of___,___, do solemnly and sincerely declare—

1.	That I am of the age of twenty-one years and upwards.
2.	That I am the person who, subject to the provisions of "The Land for Settlements Act, 1894," "The Land for Settlements Act Amendment Act, 1896," and the regulations made thereunder, am applying for a lease in perpetuity of one of the allotments described in the foregoing application.
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 I am not, directly or indirectly, either by myself or jointly with any other person or persons, the owner, tenant, or occupier of any land whatsoever under "The Land for Settlements Act, 1894," or its amendments, nor the owner in fee- page 24 simple, nor the tenant or occupier under a [unclear: lease] for a ted whereof not less than two years are unexpired, of any other [unclear: la] in the colony which, with the largest allotment included in [unclear: ta] foregoing application, would exceed in area 1,000 acres.
5.	That the total value of all the real and personal [unclear: properties] owned by me does not, after deducting the encumbrances [unclear: there] exceed the prescribed proportion of capital value (exclusive [unclear: of] buildings) of any allotment comprised in the foregoing [unclear: application]: And I am aware that the prescribed proportion is,— Three times, where the area of the allotment does not [unclear: exceed] 100 acres; Twice, where such area exceeds 100 and does not [unclear: exceed] 500 acres; and One and a half times, where such area exceeds 500 acres.
6.	That my answers to the foregoing questions (Nos. 1 to 11) [unclear: as] true and correct in every particular.

And I make this solemn declaration conscientiously [unclear: believe] the same to be true, and by virtue of an Act of the [unclear: General] Assembly of New Zealand intituled "The Justices of the [unclear: Ped] Act, 1882."

(Signature in full.)

Declared at___, this day of___, on thousand___, before me—

(Signature),

A Justice of the Peace in and for the Colony of New [unclear: Zealand] (or as the case may be).

Received on___, at___Commissioner of Crown Lands.

Site of Township of Seddon.