An Act respecting the security to be given by Officers of Canada/Schedule

FORM A.

County of , Province of , to wit:

$\scriptstyle {\left.{\begin{matrix}\ \\\ \end{matrix}}\right\}\,}$

I, A. B., the obligor (or one of the sureties), in the annexed Bond named, make oath and say, as follows:

1. I am seized and possessed to my own use of real, or real and personal estate in the Province of , in Canada, of the actual value of $ , over and above all charges upon or incumbranees affecting the same.

2. My Post Office address is as follows:

Sworn before me, at , in the County of , this day of , A. D. one thousand eight hundred and sixty

J. P., for the County of , in the Province of